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PRACTICAL    TREATISE 


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DISEASES  OF  THE  UTERUS, 


OVARIES  AND  FALLOPIAN  TUBES^ 


A.   COURTY, 

PROFESSOR   OF    CLINICAL    SURGERY,    MONTPELLIER,    FRANCE. 

TEAXSLATED    FKOM    THE    THIKD    EDITION 

BY    HIS    PTJPIL 

AGNES  M'LAREN,  M.D.,  M.K.Q.C.P.I. 
WITH  A  PKEFACE 

BY 

J.  MATTHEWS  DUNCAN,  M.D.,  LL.D.,  F.R.S.E. 

OBSTETRIC    PHYSICIAN   TO    ST.    BARTHOLOMEW'S    HOSPITAL,    LONDON. 


PHILADELPHIA: 

P.   BLAKISTON,    SON   &    CO., 

No.  1012  Walnut  Street. 

1883. 


30/ 


c^^ 


.  LA  PRECISION  DU  DIAGNOSTIC  ET  L  OPPORTUNITE  DU 
TRAITEMENT  SONT  LES  SEULS  GARANTS  DE  SUCCES  DANS  LA 
PRATIQUE." 


PREFACE. 


In  recent  times  gynaecology  lias  been  developed  in  a  very 
remarkable  manner ;  and  while  there  can  be  no  doubt  that,  on 
the  whole,  the  luxuriant  growth  is  healthy  and  beneficent,  it 
is  also  certain  that  much  of  it,  both  in  theory  and  in  practice, 
is  rank  and  doomed  to  destruction,  or  at  least  oblivion.  Too 
little  of  the  spirit  and  method  of  science  has  as  yet  permeated 
gynascology,  and  in  this  respect  its  state  may  be  contrasted  with 
that  of  the  nearly  allied  department  of  obstetrics. 

This  modern  development  of  gynaecology  began  in  France 
in  the  earlier  years  of  this  century,  and  a  kind  of  medical  en- 
thusiasm soon  appeared,  which  graduall}^  grew  and  overspread 
G-reat  Britain,  G-ermany  and  America.  It  would  be  hard  now 
to  say  where  the  still-growing  enthusiasm  is  most  prevalent. 
It  has  extended  over  the  whole  world,  and  several  unassailable 
statistical  statements  have  been  made  (Dr.  James  E.  Chadwick), 
which  render  it  probable  that  nowhere  does  gj^n^ecology  thrive 
so  vigorously  as  in  the  United  States  of  America.  'New  hos- 
pitals, books,  journals,  societies,  practitioners,  specially  devoted 
to  it,  are  now  to  be  found  in  all  parts  of  the  globe  in  greater 
or  less  number,  and  can  be  counted  and  valued;  and  those  of 
the  great  French  nation  hold  a  distinguished  place. 

Among  books  devoted  to  diseases  of  women  none  has  been, 
or  is,  more  important  than  that  of  Professor  Courty,  of  Mont- 
pellier.  It  is  the  carefully  elaborated  and  repeatedly  revised 
work  of  a  man  at  once  imbued  with  the  science  and  immersed 
in  the  practice  of  gynaecology,  of  one  who  has  long  lived  in  a 
centre  of  general  science  and  learning,  amidst  an  abounding 
population,  and  who  enjoys  the  great  advantage  of  couibining 
in  his  sphere  of  practical  activity  Ijoth  hospital  and  private 
patients — two  classes  which  differ  in  their  circumstances  and  in 
their  aspects  for  observation,  favorable  and  unfavorable  to  the 
student. 


VI  P  E  E  F  A  C  E. 

It  is  certainly  a  boon  to  the  English-speaking  peoples  to  have 
Courty's  work  translated ;  for  the  great  mass  of  medical  men 
are,  unfortunately,  ignorant  of  French,  or  not  familiar  enough 
with  that  lano;uao;e  to  enable  them  to  use  the  book  in  its 
original  form. 

This  translation  of  a  work  on  women  has  been,  with  striking 
appropriateness,  executed  by  a  woman  doctor.  I  have  had  the 
privilege  of  her  friendship  since  her  childhood,  and  know  her 
excellent  qualities.  She  has  already,  by  original  work,  shown 
her  competence  in  an  important  respect  for  this  now  completed 
task  of  translation.  But  she  is,  in  addition,  specially  qualified, 
having  studied  in  the  University  of  Montpellier,  under  Dr. 
Courty  among  others,  and  having,  subsequently  to  her  gradua- 
tion, been  for  a  considerable  time  his  assistant  in  practice. 
Moreover,  since  she  settled  in  Edinburgh,  Dr.  M'Laren  has,  in 
her  own  practice,  maintained  her  familiarity  with  the  diseases 
treated  of  in  this  book. 

Courty's  work  has,  since  its  first  publication,  been  recognized 
everywhere  as  an  exponent  of  French  doctrine.  In  France  its 
position  is  attested  by  the  sale  of  two  editions,  numbering,  I 
am  told,  10,000  copies;  and  by  the  appearance  of  another,  the 
third  edition.  It  is  from  this  third  edition  that  this  translation 
has  been  made.  The  translation  is  not  a  simple  reproduction 
in  English  of  the  chapters  of  the  third  French  edition,  for  it 
has  been  abridged  by  omissions  planned  by  the  author  himself. 
As  it  now  appears,  it  is  a  treatise  on  the  diseases  of  the  uterus. 
Fallopian  tubes  and  ovaries,  with  an  introductory  chapter  on 
the  anatomy,  physiology  and  teratology  of  the  organs  of 
generation.  I  recommend  to  the  carefal  study  of  my  profes- 
sional brethren  a  book  which  has  already  been  crowned  by  the 
Institute  of  France. 

J.  MATTHEWS  DUNCAN. 


CONTENTS 


INTEODUCTION 

ON  THE  ANATOMY,  PHYSIOLOGY,  AND  TERATOLOGY  OF  THE 
ORGANS  OF  GENERATION 

PAGE 

The  Ovaries  and  Fallopian  Tubes — the  Uterus — Ligaments  and  Append- 
ages of  the  Uterus — Changes  in  the  Uterus  at  Different  Stages — 
Structure  of  the  Uterus — the  Vagina  and  Yulva — Development : 
Comparison  of  the  Genital  Economy  in  the  Two  Sexes — Anomalies  .         3 


PART   I 

GENERAL  SURVEY  OF  UTERINE  DISEASES 

CHAPTER  I 

Diagnosis  of  Uterine  Diseases  in  General — -Presumptive  Signs  furnished 
by  the  Symptomatology  of  Uterine  Diseases — Certain  Signs  furnished 
by  Direct  Exploration  .  .  .  .  .  .95 

CHAPTER  n 

Treatment  of  Uterine  Diseases  in  General — Indications  to  be  Fulfilled  in 
the  Treatment  of  Uterine  Diseases — Methods  of  Treatment  and 
Various  Medications — Means  of  Fulfilling  Indications  in  the  Treat- 
ment of  Uterine  Diseases        .  .  .  •  .  .151 

CHAPTER  III 

General  Characteristics  of  Uterine  Diseases — Their  Frequency — Predis- 
posing Causes — General  and  Local  Symptoms — Complications — 
Prognosis — Classification  ......     233 


Vlll  CONTENTS 


PAET  II 

UTERINE  DISEASES  Df  DETAIL 

CHAPTER  I  PAGE 

Functional  Disorders. — Menstruation — AmenorrHosa — Retention  o£  the 
Menses — Deviation  of  the  Menses  and  Supplementary  Menstruaiion 
— Djsmenon'hoea — Uterine  Neuralgia — Uterine  Hemorrhage  .     257 

CHAPTER  n 

Changes  of  Position — Displacements — Deviations — Flexions — Inversion  .     343 

CHAPTER  m 

Morhid  States  without  Neoplasm — Fluxion — Congestion — Engorgement — 
Metritis^Ovaiitis  and  Salpingitis — Peri-uterine  Inflammation — of 
Leucorrhcea  in  General  and  Uterine  Catarrh  in  Particular — Hyper- 
trophy  and  Atrophy — Granulations  and  Fungosities — Ulceration 
and  Ulcers  of  the  Uterine  Cervix        .....     460 

CHAPTER  IV 

Organic  Alterations — Fihrous  Tumours — Polypi  and  Moles — Tubercle — 

Cancer  .......••     648 

CHAPTER  V 

Diseases  of  the  Uterine  Appendages — Pelvic  Haemorrhages  and  Peri- 
uterine  Hematocele — Cyst  of  the  Ovary  and  Genito-pelvic  Tumour — 
Sterility  ........     714 

Index         .  ...  .  .  •  •  •  •  •    803 


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ON  THE  DISEASES  OF  THE  UTERUS,  OVARIES 
AND  FALLOPIAN  TUBES 


INTEODUOTION 

ON  THE  ANATOMY,   PHYSIOLOGY,  AND  TERATOLOGY  OF  THE 
OEGANS   OF   GENERATION 

THE  OVAEIES  AND  FALLOPIAN  TUBES  —  THE  TJTEEUS  —  LIGAMENTS  AND  AP- 
PENDAGES OF  THE  UTERUS  —  CHANGES  IN  THE  UTEEUS  AT  DIFFERENT 
STAGES  —  STEUCTUEE  OF  THE  UTEEUS  —  THE  VAGINA  AND  VULVA  —  DE- 
VELOPMENT :  COMPARISON  OF  THE  GENITAL  ECONOMY  IN  THE  TWO  SEXES 
— ANOMALIES. 

Before  entering  on  the  pathology  of  the  uterus  and  ovaries,  it  is 
indispensable  to  know  their  anatomy  and  physiology  thoroughly.  This 
preliminary  study  is  more  necessary  with  regard  to  these  organs  than 
any  others,  because  till  within  the  last  few  years  it  has  been  very 
superficial.  I  do  not  refer  merely  to  the  organic  structure  of  the  uterus 
and  its  mucous  membrane,  to  the  histology  of  the  ovaries,  their  func- 
tions, and  all  the  points  of  anatomy  and  physiology  relative  to  irritation, 
menstruation,  conception,  pregnancy,  &c.,  on  which  light  has  only 
been  thrown  by  modern  investigations ;  but  even  the  position,  direction, 
volume,  and  mutual  relationship  of  these  organs,  with  the  modifications 
which  they  undergo  according  to  age  and  various  circumstances,  have 
been  described  in  a  most  imperfect  manner  till  quite  recently.  This  is 
due  to  the  fact  that  there  are  no  other  organs  whose  position,  form, 
size  and  structure  are  so  variable.  Age,  exercise  or  rest,  menstrua- 
tion or  pregnancy,  not  to  speak  of  various  morbid  conditions,  modify 
the  anatomical  characters  so  much,  that  differences  between  writers  are 
easily  accounted  for. 


INTRODUCTION 


The  Ovaries  and  Pallopian  Tubes 

The  ovaries  and  Fallopian  tubes  constitute  the  internal  genital 
economy. 

Ovaries} — The  ovaries  (pvaria)  are  the  organs  in  which  the 
ova,  i.e.  the  female  germs,  are  formed.  The  ovum  is  not  complete 
till  fecundation  has  taken  place,  i.e.  the  union  of  the  female  with  the 
male  germs  produced  by  the  testicles.  Hence  the  name  testes  muliehres 
given  to  the  ovaries,  to  recal  the  analogy  existing  between  organs  whose 
products  have  an  analogous  destination.  The  ovaries  lie  in  the  cavity 
of  the  pelvis,  on  each  side  of  the  uterus,  in  the  posterior  fold  [meso- 
varium)  of  the  broad  ligament  (Fig.  1) ;  but  this  position  is  variable  : 
at  birth  they  are  on  a  level  with  the  iliac  fossa,  and  only  descend  into 
the  pelvis  at  the  tenth  year.  These  organs  are  very  mobile,  their 
position  not  being,  so  to  speak,  fixed.  Certainly  they  are  enclosed  in 
the  posterior  fold  of  the  broad  ligament^  behind  the  Fallopian  tubes 
and  in  front  of  the  rectum,  from  which  they  are  usually  separated  by 
the  inferior  circumvolutions  of  the  ileum  ;  their  superior  surface  corre- 
sponds with  the  central  fold  and  with  the  intestinal  circumvolutions ; 
their  inferior  surface  with  the  posterior  surface  of  the  broad  ligaments 
and  with  the  utero-sacral  ligaments ;  their  superior  and  posterior 
border  is  convex  and  free,  and  is  in  relationship  with  the  small  intestines. 
They  are,  however,  at  the  same  time  so  mobile  that  they  may  undergo 
all  the  displacements  to  which  they  are  liable  from  the  neighbouring 
organs,  and  which  may  be  divided  into  four  classes — 1.  Displacements 
owing  to  the  laxity  of  the  posterior  fold,  very  limited,  generally 
momentary;  transverse  and  vertical.  2.  Displacements  due  to  the 
laxity  of  the  broad  ligaments,  usually  momentary,  produced  by 
fulness  of  the  bladder,  on  which  the  ovaries  rest,  and  which  pushes 
them  back  above  the  utero-sacral  ligaments.  3.  Displacements  caused 
by  enlargement  of  the  uterus,  which  drags  the  ovary  successively  from 
the  pelvis  into  the  hypogastric,  the  umbilical,  the  lumbar  and,  after 
delivery,  into  the  iliac  regions.  4.  Lastly,  accidental  or  morbid 
displacements,  such  as  hernise,  which  take  place  through  the  natural 
orifices  or  through  lacerations. 

The  form  of  the  ovary  is  that  of  an  ovoid  slightly  flattened,  pre- 
senting two  surfaces  (an  antero-superior  and  a  postero-inferior),  two 
borders  (the  superior  free,  the  inferior  adherent),  two  extremities  (one 

^  See  Klebs,  Die  Eierstoclcseier  der  Wirhelthiere,  in  Vircliow's  Arcliiv,  1861, 
Bd.  xxi,  p.  362,  and  Bd.  xxviii,  p.  301.  Schron,  Beitriige  zur  Kenntniss  zur 
Anatoin.  u.  Physiol,  der  Eierstoches  der  Saiigethiere  (Zeitschr.  von  Slebold  u. 
Kolliher,  Bd.  xii,  1863,  pp.  409  and  426).  Grohe,  TJeber  den  Bern  u.  das 
Wachsthum  des  menschlichen  Eierstoches  u.  ueher  einige  hranhliafte  Storungen 
derselben,  in  Virclww''s  Arcliiv,  1863,  Bd.  xxvi,  p.  271,  and  Bd.  xxviii,  p. 
670.  Pfliiger,  Ueher  die  Eierstoche  der  Saiigethiere  ii.  des  Menschen. 
Leipsic,  1863.  His,  Beobachtungen  ilber  den  Bau  des  Sailgethier-Eierstoches, 
in  Schidtze's  Archiv  fur  inihroscojpische  Anat.,  Bd.  i,  p.  151,  1865,  Perier, 
Anatomic  et  physiologic  de  Vovaire,  these  de  conconrs  pour  I'agregation.  Paris, 
1866.     Puech,  Des  ovaires,  de  leurs  anomalies.     Pai-is,  1873. 


ANATOMYj    PHYSIOLOGY   AND  TERATOLOGY  5 

internal,  to  which  the  utero-ovarian  ligament  is  attached ;  the  other 
external,  to  which  the  tubo-ovarian  ligament  is  attached).  The  size 
varies,  depending  on  age,  menstruation,  pregnancy  and  the  menopause.^ 
The  weight  during  the  intercalary  period  is  on  an  average  about  a 
quarter  of  an  ounce.  The  surface,  at  first  smooth  and  polished,  then 
vesicular  and  irregular,  becomes  after  a  time  covered  with  cicatrices 
and  finally  shrivelled.  The  colour,  rose  pink  in  the  child  and  red  in 
the  adult  owing  to  vascular  injection  and  sanguineous  congestion  at 
the  monthly  periods,  becomes  greyish  or  brown  after  the  menopause. 

According  to  numerous  researches,  the  results  of  which  are  still  in- 
complete, the  ovary  seems  to  be  composed  of  two  parts  :  one  adherent, 
central,  the  hilum  of  the  gland  (hilus  ovarii),  which  is  spongy,  erectile, 
and  forms,  so  to  speak,  the  bulb  of  the  ovary  (ovarian  bulb,  Rouget) ; 
the  other  cortical,  superficial,  free,  peripheric,  white  in  colour,  the  exclu- 
sive seat  of  the  formation  of  the  Graafian  vesicles  and  of  the  ovules 
(see  Figs.  3,  6,  and  7).  The  central  part,  called  medullary,  of  a  dark  red, 
is  highly  vascular,  and  furnished  with  muscular  fibres.  The  ovarian 
or  utero-ovarian  artery,  analogous  to  the  spermatic,  coming  from  the 
aorta,  supplies  the  uterus  as  it  passes  along  its  border  till  it  reaches 
the  cervix,  where  it  anastomoses  with  the  uterine  artery,  a  branch  of 
the  internal  iliac.  It  gives  off  ten  or  twenty  branches  to  the  ovary  on 
a  level  with  the  hilum,  helicine  arterioles  like  those  of  the  cavernous 
bodies  of  the  penis,  a  disposition  which  seems  common  to  the  erectile 
organs.  The  veins,  much  more  numerous,  constitute  at  first  a  wonder- 
ful venous  network  with  muscular  trabeculse  (Rouget),  which  rests 
on  the  subovarian  plexus,  a  spongy  body  somewhat  less  than  the  bulb 
of  the  vestibule,  which  plexus  communicates  below  with  the  vaginal 
plexus,  above  with  the  pampiniform  plexus  (more  developed  than  in 
the  male),  to  empty  itself  into  the  renal  vein  on  the  left  and  into  the 
vena  cava  on  the  right ;  these  veins  are  without  valves,  or  at  least  have 
very  insufficient  ones.  This  association  of  vessels  with  fasciculi  of 
smooth  muscular  fibres  in  which  they  are  enfolded,  and  the  trabeculse 
of  which  in  contracting  prevent  the  return  of  the  blood  in  the  capil- 
laries and  little  veins  into  the  venous  trunks,  gives  to  the  spongy  por- 
tion of  the  ovary  all  the  characters  of  an  erectile  organism.  The  same 
changes  probably  take  place  in  the  ovary  during  coitus  as  in  the 
testicle ;  that  is  to  say,  it  increases  to  double  its  size,  becomes  hard  and 
extremely  sensitive,  and  produces  a  considerable  hyper-secretion.  The 
lymphatics,  described  and  drawn  by  His,  are  united  into  six  or  eight 
trunks,  accompany  the  utero-ovarian  artery,  and  empty  themselves  into 
the  middle  and  superior  lumbar  lymphatic  ganglia.  The  nerves  issuing 
from  the  solar,  renal  and  lumbo-aortic  plexuses,  form  the  ovarian 
plexus,  and  accompany  the  ovarian  vessels. 

The  cortical  glandular  portion  alone  includes  those  numerous  cells 
which  do  not,  strictly  speaking,  constitute  ova  from  the  first,  though 
they  may  become  such  by  development. 

'  Size  of   the  ovary  in  the  adult  during  C^/-a"^^^^'^?,f^^^«^e^'  ^'^^l  "^• 
inter-menstmation      \         .         .         .        ^     Vertical  ditto  _        .      O"  18    „ 

(^  Antero-postenor     .      O'Olo    „ 


INTEODUOTION 


The  ovarian  vesicles,  Graafian  vesicles,  ovisacs  of  Barry,  which  con- 
tain the  ovum  and  expel  it  with  their  liquid  contents  at  the  moment  of 


Fig.  2. — General  view  of  the  vascular  supply  of  the  internal  genital  organs, 
pv,  semi-circular  enlargement  of  the  vaginal  plexus ;  PC,  cervico-uterine 
plexus ;  pu,  uterine  plexus ;  sp,  helicine  arteries  of  the  body  of  the 
uterus  ;  h,  helicine  arteries  of  the  hilus  of  the  ovary. 

dehiscence,  are  developed  on  the  cortical  portion  so  early  that  they  are 
seen  in  the  foetus  in  such  abundance  that  they  may  be  said  to  be  innu- 
merable.^ Erom  this  we  may  judge  of  the  facility  with  which  multi- 
locular  cysts  are  developed  and  of  the  early  age  at  which  they  may  be 
observed.  It  is  only  in  proportion  as  they  are  developed  that  the 
ovarian  vesicles  project  beyond  the  cortical  substance  of  the  ovary, 
forming  on  one  side  a  projection  on  its  free  surface,  and  on  the  other 
penetrating  more  and  more  deeply  into  the  bulbous  portion,  where  they 
were  erroneously  supposed  to  take  their  origin.  The  ovisac  is  spherical, 
attaining  a  size  of  15  milHmetres  or  more  in  diameter;  it  hollows  out 
for  itself  a  cavity  in  the  ovary,  the  wall  of  which  has  been  mistaken 
for  its  supposed  external  membrane.  Its  proper  envelope,  semi-trans- 
parent, grey  or  reddish,  resistant  and  capable  of  being  enucleated 
from  the  ovary  to  which  it  is  only  attached  by  fibrous  tissue  and  small 
vessels,  is  composed  of  laminar  fibres  or  fibrous  tissue,  of  fusiform  bodies, 
of  embryo-plastic  nuclei,  of  amorphous  granular  matter,  of  cells  peculiar 

*  Sappey,  Anat.  Descriptive,  p.  631.     Paris,  1864.      Kolliker  has  counted 
more  than  6000  on  each  ovary  {Mih-oscop.  Anat.     Leipzig,  1852). 


ANATOMY,    PHYSIOLOGY   AND    TERATOLOGY  7 

to  the  ovisac,  and  of  abundant  capillaries.^  The  ovisac  is  supplied 
with  blood  by  two  or  four  arterioles,  which  spread  over  its  surface  in  a 
delicate  network.  The  memhrana  granulosa  or  epithelium  of  the  ovi- 
sac, formed  of  one  or  more  layers  of  hemispherical  cells,  has  a  thickness 
of  from  1  to  2  hundredths  of  a  millimetre,  except  at  one  point  where 
there  is  a  thickness  of  GO  hundredths  of  a  millimetre  and  which  has 
received  the  name  of  cumulus  or  discus  proligerus^  because  it  bears  the 
germ. 

The  ovum^  lies  in  the  centre  of  the  cumulus  and  according  to  the 


Fig.  3. — Vertical  section  of  the  ovary  of  the  cat  during  gestation.  Injected. 
Magnified  60  diameters.  1,  cells  of  the  non-vascular  cortical  layer ; 
2,  cortical  cells  presenting  the  first  rudiment  of  the  meinbrana  germina- 
tiva,  and  the  first  trace  of  a  vascular  circle  ;  3,  commencing  enlargement 
of  follicle,  separation  of  the  memhrana  germinativa  of  the  ovum,  and 
continuation  of  this  membrane  into  the  adjoining  portion  of  the  follicle  ; 
4,  formation  of  proligerons  disc.  Vascular  network  of  follicle  ;  5  to  8, 
follicles  at  various  periods  of  development ;  9,  small  follicle  from  which 
the  section  has  only  removed  a  disc  from  the  zona  pellucida  of  the  ovum  ; 

10,  half-opened  follicle,  the  ovum  of  which  has  escaped  by  the  section  ; 

11,  intact  portion  of  the  follicular  wall,  through  which  the  zona  pellucida 
is  seen ;  12,  central  vein  of  corpus  luteum ;  13,  peripheric  artery  of  corpus 
luteum  :  the  branches  of  this  artery  surround  the  polygonal  cells  of  the 
corpus  luteum ;  14,  large  vessels  of  ovarian  stroma  (after  Schroen). 


'  Courty,  De  I'oeuf  et  de  son  developpement,  p.  55.  Montpellier,  1845. 
Robin,  Mchnoire  sur  les  modifications  de  la  muqueuse  uterine,  p.  160. 

^  I  prefer  this  name  to  that  of  ovule  for  designating  the  female  germ ;  the 
latter  gives  a  false  idea,  since  Baer,  who  invented  it,  meant  it  to  convey  a 
distinction  as  incorrect  as  subtle  between  the  ovum  of  birds  and  that  of  the 
mammalia  :  the  latter  having,  according  to  him,  an  ovum  in  an  ovum,  or  an  ovum 
raised  to  the  second  power.     In  both  cases  there  is  an  ovum  in  question,  which 


8 


INTEODUOTION 


observations  of  Schroen,  Eobin,  &c.,  at  the  nearest  point  to  the  arterioles 
which  ramify  in  the  Graafian  vesicle.^ 

The  ovum  is  a  spherical  vesicle  of  from  one  to  two  tenths  of  a  milli- 
metre, with  a  very  fragile  envelope  (zona  pellucida  of  Baer  or  vitelline 
membrane  of  Coste)  and  granular  contents  {germ  or  cicatricula  in 
birds),  alone  or  surrounded  by  a  more  or  less  considerable  quantity  of 
vitellus,  presenting  in  its  centre  the  nucleus  of  the  cell  (germinal  vesicle 
of  Purkinje)  and  its  nucleolus  (germinal  spot  of  Wagner),  discovered 
by  Coste  in  the  germinal  vesicle  of  the  human  ovum.  Two  ova  may 
be  found  exceptionally  in  one  ovisac  (Baer,  Bischoff,  Bidder),  and 
certain  anomalies  have  been  observed  by  Davaine  ^  in  birds.  Under 
the  influence  of  the  ovarian  congestion  produced  by  the  natural  matu- 


FiG.  4 


Fig.  5. 


Fig  4. — Formation  of  coi'pus  luteum  of  the  ovary  (natural  size).  A,  section 
of  tlie  ovary :  a,  recently  emptied  follicle  filled  with  blood  (thrombus  of 
extravasation),  surrounded  by  a  thin  yellow  layer ;  h,  empty  follicle, 
puckered  in  front,  with  a  smaller  thrombus  and  a  thicker  wall ;  c,  retro- 
gressive metamorphosis  in  more  advanced  stage.  B,  exterior  surface  of 
the  ovary  and  point  where  the  recent  rupture  of  the  follicle  has  taken 
place  ;  the  thrombus  projects  outside. 

Fig.  5. — Section  of  two  corpora  lutea  of  natural  size.  1,  in  fresh  condition, 
eight  days  after  conception  ;  2,  in  the  fifth  month  of  pregnancy,  a,  tunica 
albuginea ;  b,  stroma  of  ovary ;  c,  fibrous  membrane  of  follicle,  thickened 
and  puckered  (internal  layer) ;  d,  sanguineous  clot  within  this  membrane ; 
e,  discoloured  clot ;  /,  fibrous  membrane,  forming  the  boundary  of  the 
corpus  luteum. 


does  not  differ  from  the  other  as  to  the  germ,  and  which  is  only  distinguished 
by  the  quantity  of  nutritive  matter  added  and  by  the  shell  which  protects  it. 

'  The  ovum  has  often  seemed  to  me  to  be  placed  in  the  superficial  and 
prominent  point  of  the  vesicle,  opposite  the  little  vascular  trunks  which  spread 
by  iiTadiation  over  the  ovisac.  This  is  shown  very  clearly  in  the  beautiful 
woodcuts  which  Gerbe  has  drawn  so  conscientiously  for  Coste's  groat  work  ;  I 
have  not,  however,  prosecuted  my  researches  on  this  point  so  far  as  to  be  able 
to  affirm  that  it  is  always  so. 

^  Comptes  rendus  de  la  Socicte  de  biologie.    Paris,  1860. 


x^NATOMY,  PHYSIOLOGY  AND  TEEATOLOGY  9 

ration  of  the  vesicle  and  by  the  accompanying  erectile  phenomena 
manifested  externally  by  menstruation,  or  under  the  influence  of  the 
congestion  produced  by  sexual  excitement,  the  quantity  of  fluid  in  the 
ovisac  increases  rapidly,  stretches  the  walls,  renders  them  thin,  and 
gradually  suspends  the  circulation  in  the  part  which  is  most  superficial 
and  least  resistant.  A  kind  of  linear  ulceration  with  rupture  of  the 
ovisac  follows  at  this  point :  the  ovum  is  expelled  in  the  middle  of  the 
cumulus  proligerus,  and  received  by  the  fimbriated  extremity  of  the 
Tallopian  tube. 

A  work  of  reparation  then  commences  in  the  tissue  of  the  ovisac, 
passing  through  remarkable  phases,  and  characterised  by  the  persistence, 
during  a  longer  or  shorter  period,  of  an  organic  production  which 
gradually  diminishes  in  volume,  and  which,  on  account  of  its  colour, 
has  received  the  name  of  yellow  body,  corpus  luteum  (Malpighi  ^),  or, 
as  signifying  more  exactly  the  cicatricial  act  of  which  it  is  the  indica- 
tion, the  more  correct  name  of  ovariule  (Robin) .  This  organic  product 
is  a  hypertrophic  thickening  of  the  membrane  of  the  ovisac,  the  cells 
of  which  multiply  and  increase  in  such  enormous  proportions  as  to 
cause  a  puckering  of  the  membrane,  and  a  considerable  projection 
towards  the  surface  of  the  ovary.  These  cells  are  simultaneously 
invaded  by  a  granular  product,  of  fatty  nature  and  yellow  colour, 
at  least  in  woman,  which  is  the  real  cause  of  the  colour  of  the  ovariule 
in  the  human  species.  In  cystosarcomata  of  the  ovary  I  have  seen 
this  product  invade  the  membrane  of  several  vesicular  cysts,  and 
give  rise  to  considerable  masses  of  yellow  matter.  Then  comes  the 
period  of  reabsorption ;  the  yellow  body  atrophies  and  shrivels  up  so 
much  that  in  its  place  there  remains  only  a  depressed  cicatrix  with 
the  trace  of  the  rupture  of  the  ovisac  and  a  grey  or  slaty  coloration. 

The  development  of  the  Graafian  follicles  and  of  the  ova  takes  place 
in  the  ovary  not  only  after  puberty  and  during  sexual  activity  but 
even  before  this  period  and  during  foetal  life.  In  1836  Cams  an- 
nounced that  ova  were  to  be  found  in  the  ovaries  of  the  foetus.  But 
the  Graafian  vesicles  were  considered  to  be  independent  of  each  other, 
and  the  ovary  in  consequence  diff'erent  from  other  glands.  The  recent 
researches  of  His  and  Pfliiger  prove  that  probably  it  is  not  so,  and 
that  the  ovary  resembles  the  testicle  and  other  secreting  organs. 

In  1838  Valentin"  announced  that  the  ovary  in  embryos  is  cana- 
liculated.  In  1863  Pfliiger  demonstrated  this  tubular  structure. 
Kolliker^  confirmed  the  fact  by  his  researches  on  the  embryos  of  cats, 
cows  and  women.  In  the  ovaries  of  young  embryos  cordlike  glandular 
filaments  are  certainly  seen,  sometimes  in  the  form  of  a  club  with  a 
blind  end.  They  are  composed  of  a  superficial  layer  of  little  cells 
analogous  to  epithelium  cells,  precursors  of  the  granular  membrane  of 
the  Graafian  follicle,  and  of  a  thick  mass  of  larger  cells  which  will 
become  ova. 

The  development  also  takes  place  from  the  superficial  part  of  this 

'  Metovarium,  after  the  ovriin  (Raciborski). 

2  Mailers  Archiv,  1838,  p.  531. 

^  Handbuch  Gewebelchre,  5te  Aufl,  1867.     Leipzig. 


10 


INTEODUCTION 


gland,  where  it  is  least  considerable,  to  the  deep  part,,  where  it  is  most 
so.  The  transition  of  the  glandular  filaments  containing  ova  into 
Graafian  follicles  or  sacs  takes  place  even  in  the  embryo;  it  com- 
mences in  the  interior^  and  advances  slowly  to  the  surface,  so  that 


/v 


Fig.  6. — Transverse  section  of  the  ovaiy  of  a  lauman  embryo  at  six  montts, 
magnified  six  diameters,  a,  external  layer  of  glandular  substance,  with 
glandular  filaments  cleaned  by  means  of  a  brush ;  h,  internal  layer  of  the 
same  substance,  with  ovisacs  separated  or  in  course  of  isolation  ;  c,  stroma 
of  the  hilus  (medullary  substance)  ;  d,  mesovarium,  divided  near  the 
broad  ligament  (after  His). 

whilst  the  medullary  portion  increases,  the  tolerably  thick  glandular  or 
cortical  portion  presents  an  inferior  zone  of  follicles,  separated  or  in 
process  of  separation.  The  separation  of  follicles  is  effected  by  the 
production  of  fibrous  tissue  forming  partitions,  and  by  that  of  new 
cells  of  epithelium  lining  them.  The  multiplication  of  these  partitions 
divides  the  entire  tube  into  isolated  sections,  each  smaller  than  the 
preceding,  and  each  containing  only  one  ovum  enveloped  in  a  layer  of 
epithelium.  In  proportion  as  the  follicle  increases  in  size  it  becomes 
filled  with  fluid,  and  the  granular  membrane,  with  its  proligerous  disc 
containing  the  ovum,  remains  against  the  wall.  The  vascular  wealth 
of  the  ovary  in  the  foetus  is  remarkable,  and  is  proportioned  to  the 
importance  of  the  formation  of  this  multitude  of  ovigenic  or  proli- 
gerous cells.  In  after  life  there  are  probably  periods  when  physiolo- 
gical impulses  of  normal  fluxionary  movements  singularly  accelerate 
the  evolution  of  ova.  Thus  at  birth  it  is  probable,  as  Eouget  has 
affirmed  and  as  the  secretion  of  milk  which  occurs  so  frequently  at 
that  time  would  seem  to  indicate,  that  a  hypertrophic  ovarian  con- 
gestion takes  place,  as  if  there  were  a  general  impulse  towards  the 
development  of  the  whole  being.  A  similar  impulse,  the  most  remark- 
able of  all,  occurs  at  puberty.  Movements  of  less  importance  take 
place  at  each  monthly  period.  They  cease  entirely  after  the  meno- 
pause when  the  organ  atrophies.     This  retrogressive  atrophy  makes 


ANATOMY,   PHYSIOLOGY   AND    TERATOLOGY 


11 


great  progress  in  old  age.  Measurements  of  the  ovary,  taken  by  Puech 
at  different  ages,  confirm  the  variations  in  the  size  of  this  organ  in 
these  various  circumstances. 


/'*»V-A  , 


Fig.  7. — Elementaiy  stnicture  of  the  ovaiy  in  the  human  embiyo. — A,  in  the 
embryo  of  six  months,  magnified  400  diameters.  1,  two  ova  suiTOunded 
by  an  epithelial  layer,  one  of  them  presents  a  prolongation  by  which  it 
was  probably  united  to  another  ovum  as  in  Fig.  2,  which  represents  two 
ova  united  by  a  cord  of  protoplasm  (primitive  ova)  with  their  epithelium  ; 
3,  primitive  ovum  with  two  nuclei  (germinal  vesicles).  B,  in  an  embryo 
of  seven  months,  magnified  400  diameters.  1,  superficial  layers  of  the 
ovaiy  with  voluminous  glandular  tubes,  composed  each  of  an  epithelial 
layer  and  of  a  mass  of  ova,  those  nearest  the  surface  being  smaller  than 
those  deeply  situated  in  the  glandular  substance  of  the  organ  ;  2,  ovigenic 
sacs  of  the  deep  layer  of  the  glandular  substance  at  the  time  of  separation, 
two  little  sacs  are  represented  completely  isolated,  and  two  others  (glandular 
tubes)  each  containing  two  ova  (after  KoUiker). 

The  differences  in  the  aspect  of  the  ovary  at  various  epochs  of  life 
are  due  to  the  different  phenomena  which  characterise  the  normal  evo- 
lution of  the  Graafian  vesicles.  The  imperfection  of  this  evolution 
before  puberty,  the  frequency  of  this  development  and  the  almost 
periodical  ruptures  during  the  age  of  sexual  activity,  the  atrophy  and 
disappearance  after  the  menopause,  give  to  the  surface  of  the  ovary, 
during  the  successive  ages  of  embryo  life,  childhood,  youth,  maturity, 
and  old  age,  various  aspects  ;  at  first  it  is  elongated,  then  ovoid, 
smooth,  or  indented,  with  mingled  projections  and  cicatrices,  dotted 
with  circumscribed  spots  of  various  colours — white,  blue,  or  yellow — 
till  finally  it  has  the  appearance  of  a  wrinkled,  shrunken,  shrivelled 
membrane. 


12 


INTEODUOTION 


It  will  readily  be  perceived,  by  the  size,  lengtb^  and  tongue-like 
shape  of  the   ovaries   in   the  embryo    (Pig.   8)^  by   their    dimiuu- 


FiG.  8, — The  uterus  and  its  appendages,  and  their  relations  with  the  neigh- 
houring  organs,  at  the  end  of  the  fifth  month  or  beginning  of  the  sixth, 
natural  size.  External  view :  1,  bladder,  urachus,  and  umbilical  arteries  ; 
2,  utems ;  3,  rectum ;  4,  ovaiy,  relatively  very  large,  almost  as  long  as 
the  Fallopian  tube  ;  5,  Fallopian  tube,  the  broad  portion  of  which  is 
prominent  from  early  life ;  6,  round  ligament.  Owing  to  the  defective 
development  of  the  pelvis  at  this  age  these  organs  are  situated  above  the 
brim  in  place  of  being  contained  in  the  pelvic  cavity.  Cavities  :  1,  bladder ; 
2,  uterus,  on  the  anterior  surface  of  which  the  trunk  of  the  arbor  vitce  is 
seen  extending  to  the  fundus  ;  the  isthmus,  which  ought  to  separate  the 
cavity  of  the  body  from  that  of  the  cervix,  cannot  be  distinguished  ;  3, 
vaginal  orifice  of  the  uteras  ;  4,  vagina,  the  folds  of  which  are  well  marked  ; 
5,  posterior  surface  of  the  uteras  ;  6,  rectum  ;  7,  ovaiy  ;  8,  Fallopian 
tube  ;  9,  pubic  symphysis  ;  10,  labia  minora  and  majora ;  11,  vaginal 
orifice ;  12,  anus. 


Fig.  9. — Ovary  and  fimbriated  extremity  of  Fallopian  tube  in  a  woman  who 
died  during  menstruation  (after  Farre  ad  nat.)  I,  broad  ligament ;  o, 
ovary ;  r,  r,  old  yellow  bodies,  remains  of  Graafian  follicles  ruptured 
and  cicatrised  ;  /,  broad  portion  of  the  Fallopian  tube ;  i,  fimbriated  ex- 
tremity applied  to  the  ovary. 


ANATOMY,    PHYSIOLOGY    AND    TERATOLOGY 


13 


tive  size  and  their  slightly  llattened  form  in  the  child,  by  their  in- 
creased size,  ovoid  appearance,  and  the  formation  of  globular  projec- 
tions on  their  surface  at  puberty  (l^'igs.  1,  13,  14),  in  the  adult  during 
menstruation  (Fig.  9)  and  in  the  pregnant  woman  (Fig.  10),  by 
the  return  to  smaller  dimensions  at  the  period  of  the  menopause 
(Fig.  11),  and,  lastly,  by  their  complete  atrophy  in  old  age  (Fig.  13), 
that  these  organs,  originatiug  in  little  bands  along  the  inner  borders  of 


Fig.  10. — Ovary  during  pregnancy,  and  external  view  of  yellow  body  (corpns5 
luteum)  (after  Coste), 

the  Wolffian  bodies,  hollowed  out  after  the  manner  of  blind  tubes  like 
the  testicles,  becoming  later  on  vesicular  by  the  occlusion   and  the 


Fig.  11. — Ovary  at  the  menopause. 


Fig.  12. — Ovary  in  old  age. 


partitioning  of  these  tubes,  are  congested  and  hypertrophied  during 
the  whole  period  of  maturation  of  the  ova  and  of  sexual  activity,  to 
be  reduced  to  a  kind  of  shell  or  shrivelled,  shrunken  web  after  the 
extinction  of  the  reproductive  faculty. 

Fallopian  tubes. — Contained  in  the  central  fold,  the  tubes  may 
undergo  displacements  analogous  to  those  of  the  ovaries.  Passing  off 
from  the  uterus  in  a  transverse  direction,  each  tube  describes  in  its 
external  half  a  curve,  the  concavity  of  which  looks  backwards,  inwards, 
and  downwards,  and  by  its  terminal  swelling  it  turns  towards  the 
ovary.  Its  axis,  though  straight  near  the  uterus,  before  long  presents 
flexuosities  recalling  those  of  the  vas  deferens  at  its  origin.  Its 
medium  length  is  12  centimetres.  Its  diameter  increases  with  its 
distance  from  the  uterus  :  it  is  hardly  more  than  15 -tenths  of  a  milli- 
metre at  the  opening  and  in  the  thickness  of  the  uterine  walls,  whilst  it 
is  4  millimetres  near  the  uterus,  from  5  to  (5  at  the  central  part,  from 


14 


INTRODUCTION 


7  to  8  at  its  external  extremity,  and  from  18  to  20  at  the  circumference 
of  the  terminal  infundibulum.  Therefore,  even  supposing  the  diameter 
of  the  uterine  orifice  to  be  enlarged,  it  is  not  the  less  impossible  to 
catheterise  the  Fallopian  tube.  There  is  not,  however,  the  same  diffi- 
culty about  the  penetration  of  liquids  that  there  is  about  solids,  there- 
fore an  injection  may  penetrate  from  the  uterine  cavity  into  the 
IVllopian  tube.     The  external  orifice,  ostium  abdominale,  opens  in  the 


Fig.  13. — Fallopian  tube  and  ovary.  0,  ovary  turned  downwards  and  back- 
wards ;  Od,  isthmus  of  the  tube  ;  Od',  broadest  part  of  this  canal ;  J, 
fimbriated  extremity  ;  Oa,  abdominal  orifice  of  the  tube,  Fo,  ovarian  fringe  ; 
io,  infundibulo-ovarian  ligament ;  Ro,  organ  of  Eosenmiiller. 

centre  of  a  kind  of  fringed  funnel,  called  the  fimhriated  extremity.  It 
is  not  uncommon  to  observe  accessory  fimbriated  extremities  on  the 
external  third  of  the  Pallopian  tube,  i.  e.  other  orifices  besides  the 
normal  one,  communicating,  like  it,  with  the  canal  of  the  oviduct,  and 
forming  consequently  a  condition  unfavorable  to  the  preservation  and 
transport  of  the  fecundated  ovum,  and  therefore  a  cause  of  sterility.^ 

The  Fallopian  tube  is  composed  of  a  double  muscular  tunic,  the 
internal  of  circular,  the  external  of  longitudinal  fibres,  following  all  its 
flexuosities,  and  apparently  formed  by  a  prolongation  of  the  uterine 
fibres.  These  are  the  cause  of  the  vermicular,  peristaltic  movements, 
analogous  in  every  way  to  those  of  the  intestine,  which  it  is  easy  to  see 
in  the  females  of  the  mammalia  at  the  time  of  ovulation.  Besides 
these  intrinsic  muscles,  the  Fallopian  tube  is  surrounded  by  an  ex- 
trinsic superficial  layer  of  muscular  bundles,  which  do  not  follow  the 
flexuosities  of  this  canal,  but  run  in  a  perfectly  straight  direction, 
are  continuous  with  those  of  the  utero-ovarian  and  tubo -ovarian  liga- 

*  Richard,  Anatomie  cles  trompes  cle  Vuterus,  Theses  de  Paris,  1851. 


ANATOMY,   PHYSIOLOGY    AND    TERATOLOGY 


15 


ments,  as  well  as  with  those  of  the  hilus  of  the  ovary,  determine  the 
adaptation  of  the  fimbriated  extremity  to  this  latter  organ,  and  form 
part  of  the  general  system  of  the  extrinsic  muscular  envelope  common 
to  the  uterus  and  its  appendages  which  will  be  described  hereafter. 


Fig.  14. — Section  of  right  Fallopian  tube  in  an  adult  nullipara  (after  Richard). 
a,  uterine  orifice  of  the  tube  ;  h,  narrowest  part  of  the  canal,  corresponding 
to  the  uterine  end  of  the  tube  ;  c,  canal  in  the  body  of  the  tube,  origin  of 
the  large  folds  continuing  into  the  fimbriated  extremity ;  d,  opened  fim- 
briated extremity  filled  with  folds,  which  are  continuous  with  those  of  the 
canal  of  the  tube  ;  e,  tubo-ovarian  fringe  and  furrow  of  the  same  name  ; 
f,  ovary  ;  g,  round  ligament. 

The  internal  membrane  of  the  Eallopian  tube  is  a  mucous  membrane 
furnished  with  very  remarkable  longitudinal  folds,  most  marked  in  the 
centre,  but  equally  distinct  at  the  two  ends,  on  the  one  side  on  the 
internal  surface  of  the  fimbriated  extremity,  on  the  other  in  the  uterus 
at  each  of  the  superior  angles.  Henning  has  found  in  the  tubal 
mucous  membrane  glands  which  are  short,  bursiform,  simple,  or 
dichotomous ;  some  present  a  swelling  in  the  form  of  a  cluster,  others 
show  circumvolutions  analogous  to  those  of  the  intestine  and  sudori- 
parous glands,  and  are  arranged  parallel  to  the  mucous  membrane. 
They  are  especially  numerous  on  a  level  with  the  abdominal  extremity. 
The  epithelium  of  this  mucous  membrane  is  vibratile,  the  cilia  moving 
from  the  ovary  towards  the  uterus. 

The  Fallopian  tubes  have  a  double  action  to  fulfil :  on  the  one  hand 
they  convey  the  spermatozoa  to  the  ovule  to  be  fecundated,  and  on  the 
other  hand  they  transmit  this  ovule  to  the  uterus,  where  it  ought  normally 
to  be  developed.  We  may  presume  that  the  transport  of  the  ovule  is 
effected  in  part  by  the  vibratile  cilia  of  the  tubal  mucous  membrane. 


16 


INTRODUCTION 


The  Uterus 

The  uterus  is  a  hollow  organ  designed  for  gestation.  In  shape  it 
is  like  a  cone  flattened  from  before  backwards,  having,  consequently, 
two  surfaces  (one  anterior  and  one  posterior)  and  lateral  borders. 
The  base  or  fundus  is  above,  the  apex  below.  The  flattening  is  not 
equal  on  the  two  surfaces ;  the  anterior  alone  is  almost  flat,  the  poste- 


FiG.  15. — Uterus  of  an  adult  nullipara  (posterior  surface),  a,  body  of  the 
uterus  ;  c,  cervix  ;  r,  isthmus  or  contraction  indicating  the  junction  of  the 
body  with  the  cervix  ;  s,  fundus  ;  1 1,  lateral  borders  ;  //,  Fallopian  tubes  ; 
V,  insertion  of  vagina  ;  i,  vaginal  portion  of  cervix  ;  o,  external  orifice. 


rior  is  convex,  and,  as  it  were,  divided  into  two  parts  by  a  projection 
running  the  whole  length  of  the  median  line.  The  isihmtis,  a  slight 
annular  depression  situated  on  the  surface  of  the  organ  immediately 
below  the  middle,  more  marked  before  and  on  the  sides  than  behind, 
is  the  external  vestige  of  its  division  into  two  unequal  parts,  an 
upper  one,  the  6od?/,  larger  and  cone  shaped,  a  lower  one,  the  nec&, 
cylindrical  and  slightly  swollen  in  the  middle. 

Volume. — If  we  take  into  account  neither  individual  varieties  nor 
functional  variations  the  following  are  the  dimensions  in  round 
numbers : 


Length  . 
Breadth . 
Thickness 


0-060  m.  to  0-070  m. 
0-035  „  to  0.045  „ 
0-020  „  to  0-025  „ 


I  may  mention  that  the  length  may  reach  80  millimetres  without 
the  existence  of  any  morbid  condition;  that  the  breadth  from 
one  Pallopian  tube  to  the  other  is  the  most  difficult  to  determine 
either  in  the  patient  or  on  the  cadaver,  whilst  the  thickness,  or  the 
antero-posterior  diameter,  measured  at  its  culminating  point,  is  nor- 
mally the  least  variable  and  the  one  in  which  it  is  easiest  to  discover 
pathological  changes. 


ANATOMY,    PHYSIOLOGY   AND    TERATOLOGY 


17" 


Weight. — The  weight  of  the  uterus  is  on  an  average  an  ounce  and 
a  halfj  but  it  varies,  as  do  also  the  form  and  the  size  in  different 
physiological  conditions  of  the  organ. 

Direction. — The  vulva  is  almost  in  the  plane  of  the  inferior  strait, 
projecting  a  little  beyond  it  below.  The  vagina  commences  by  being 
in  the  same  axis,  but  as  it  rises  it  has  a  tendency  to  follow  the  curve 
of  the  sacrum ;  as  for  the  uterus,  it  is  in  the  axis  of  the  superior  strait, 
by  which  it  is  evident  that  it  forms  a  continuation  of  the  vagina  by 
making  an  angle  at  the  point  of  union  of  the  two  organs.  The  axes, 
even  of  the  body  and  neck  of  the  uterus,  are  not  absolutely  the  same, 
the  neck  following  slightly  the  curve  of  the  sacrum,  or  the  axis  of  the 


Fig.  16. — Central  vertical  section  showing  the  direction  of  the  uterus  and 
chief  relations  of  this  organ,  u,  uterus  ;  w,  vagina  opened  ;  v,  the  bladder 
opened  ;  i,  urethra  opened  ;  r,  rectum  opened  ;  o,  anterior  peritoneal  or  utero- 
vesical  cul-de-sac ;  t,  posterior  peritoneal  or  utero-vagino-rectal  cul-de-sac. 
It  is  easily  seen  that  these  culs-de-sacs  are  situated  on  very  different  levels. 
n,  connection  of  the  vagina  with  the  uterus  and  utero-vaginal  circular 
cul-de-sac  ;  a,  connection  of  the  bladder  with  the  uterus  ;  c,  recto- vaginal 
septum,  thin  above,  m,  where  the  walls  of  the  vagina  and  rectum  are 
almost  contiguous,  thick  below  at  p,  where  it  forms  the  perineum  ;  s,  left 
half  of  the  symphysis  pubis. 

pelvis  proper  passing  in  front  of  the  vagina,  the  body  inclining  a 
little  forwards,  so  that  its  fundus  looks  towards  the  anterior  abdo- 
minal wall  and  its  axis  is  perpendicular  to  the  level  of  the  brim. 
There  is  in  fact  normally,  as  a  rule,  a  slight  anteversion,  and  even 
anteflexion,  the  uterus  having  a  tendency  to  fall  forwards  rather  than 
backwards.  The  fundus  of  the  uterus  generally  inclines  to  the  right, 
especially  during  pregnancy.  Is  this  owing  to  the  sigmoid  flexure 
being  to  the  left  ?  Mauriceau  and  Ereund  think  that  the  relative 
shortness  of  the  right  appendages  is  the  effect  and  not  the  cause  of 
this  inclination,  which  is  congenital. 

Relations. — The  uterus  is  situated  in  the  pelvis  behind  the  bladder. 
The  body  is  free  and  smooth,  and  covered  in  front  by  the  peritoneum, 

2 


18 


INTEODUOTION 


which  adheres  closely  to  it  in  the  upper  part,  less  so  below,  and  on  a 
level  with  the  isthmus  is  reflected  on  the  posterior  surface  of  the 
bladder.  This  vesico-uterine  cul-de-sac  is  situated  high  up  in  the 
child,  lower  in  the  adult,  and  low  down  in  the  multipara  and  in  the 
old  woman,  owing  to  the  differences  which  age  and  parturition  cause 
in  the  relative  proportions  of  the  body  and  neck.  It  may  vary  to  a 
certain  extent  independently  of  these  conditions ;  as  a  rule,  however, 
it  corresponds  with  the  isthmus.  Below  this  point  the  anterior  surface 
of  the  cervix  is  in  immediate  contact  with  the  lower  and  posterior  part 
of  the  bladder,  to  which  it  is  attached  by  cellular  tissue.  The  bladder 
adheres  to  the  cervix  for  a  length  of  14  millimetres.  It  is  adherent 
to  the  vagina  by  all  the  surface  corresponding  to  the  vesical  trigone, 
and  by  a  portion  of  the  vesical  walls  beyond  the  trigone,  i.  e.  by  almost 
the  whole  of  its  fundus,  and  by  all  the  breadth  of  the  anterior  vaginal 
wall,  a  space  almost  quadrilateral  in  form  and  extending  from  27  to 
30  millimetres  in  every  direction  (Fig.  18  b,  b). 


Fig.  17. 


Fig.  18. 


Fig.  17. — Exact  relations  of  the  bladder  with  the  uterus  and  vagina  (after 
Dubois),      m,  uterus ;    c,  cervix  ;    u,  u,  ureters ;    t,  trigone  of   bladder ; 

a,  a,  line  of  connection  between  the  bladder  and  cervix  ;  the  quadilateral 
space  enclosed  in  the  dotted  lines,  r,  u,  u,  r,  including  the  trigone,  repre- 
sents the  surface  of  attachment  of  the  bladder  to  the  vagina. 

Fig.  18. — Vertical  antero-posterior  section  of  the  uterus,  i,  isthmus  separating 
the  cavity  of  the  body  from  that  of  the  cervix  ;  a,  anterior  lip  of  the  cervix  ; 
p,  posterior  lip  ;  /,  posterior  vagino-uterine   cul-de-sac  ;    va,  va,  vagina  ; 

b,  b,  connections  of  the  urinary  bladder  with  the  anterior  surface  of  the 
cervix ;  r,  reflexion  of  the  peritoneum  from  the  posterior  surface  of  the 
uterus  and  vagina  to  the  rectum ;  c,  commencement  of  the  utero-lumbar 
suspensory  ligaments. 


ANATOMY,    PHYSIOLOGY    AND    TERATOLOGY  19 

The  result  of  a  great  number  of  measurements  taken  at  all  ages, 
both  in  the  state  of  vacuity  and  of  gestation^  is  that  the  distance 
between  the  opening  of  the  ureter  at  the  jDOsterior  angle  of  the  trigone 
and  the  insertion  of  the  vagina  at  the  cervix,  while  very  variable,  is 
on  an  average  from  1  to  2  centimetres.  The  distance  between  this 
opening  and  the  free  portion  of  the  cervix  is  still  more  variable  as  it 
depends  on  the  size  and  length  of  the  cervix.  The  distance  between 
the  ureter  and  the  margin  of  the  uterus  is  equally  variable,  since  the 
ureter  is  sometimes  at  some  distance  from  it,  whilst  in  other  circum- 
stances, as  at  the  end  of  gestation,  it  is  in  immediate  contact  with  the 
uterine  border,  as  shown  by  the  fact  that  the  ureter  and  uterus  may 
be  torn  or  ulcerated  at  the  same  point,  as  occurred  in  a  case  of  fistula 
after  delivery  which  came  under  my  own  observation.  When  the 
bladder  is  empty  the  anterior  surface  of  the  uterus  is  bent  over  it, 
forming  a  slight  curve  with  the  concavity  looking  forwards  and  down- 
wards. When  it  fills,  this  surface  rises  and  is  directed  in  turn 
forwards  and  upwards.  When  it  is  distended  the  uterus  may  be  com- 
pressed by  it  against  the  sacro- vertebral  angle,  or  if  the  ligaments  are 
relaxed  may  even  be  turned  backwards,  its  base  looking  towards  the 
concavity  of  the  sacrum,  and  may  become  fixed  in  this  position  when 
such  a  displacement  occurs  at  the  commencement  of  pregnancy  or  after 
delivery.^  The  posterior  surface  of  the  uterus  is  covered  in  all  its 
extent  by  the  peritoneum,  which,  as  it  passes  over  the  utero-sacral 
hgaments,  forms  at  the  sides  Douglas's  folds,  whilst  in  the  middle  line 
it  extends  to  the  upper  part  of  the  posterior  vaginal  wall  to  form,  by  its 
reflection  on  to  the  rectum,  the  recto-vaginal  culde  sac  (Fig.  18  r). 
The  posterior  surface  assumes  alternate  positions  exactly  the  reverse  of 
the  anterior  surface,  according  as  the  bladder  is  full  or  empty.  It  looks 
towards  the  rectum,  being  generally  separated  from  it  by  circumvolu- 
tions of  the  small  intestine,  though  exceptionally  it  may  rest  upon  it 
when  raised  and  pushed  towards  it  by  the  distension  of  the  bladder 
or  by  one  of  the  pathological  conditions  which  will  occupy  our  atten- 
tion when  studying  displacements  of  the  womb. 

The  upper  margin  is  in  relation  with  the  circumvolutions  of  the 
small  intestine,  of  which  it  somewhat  retains  the  impression.  In 
the  majority  of  women  it  does  not  reach  the  level  of  the  brim 
(Sappey).  However  it  extends  beyond  the  horizontal  plane,  passing 
immediately  above  the  symphysis  of  the  pubis,  which  allows  of  its 
being  examined  by  palpation  in  the  greater  number  of  patients. 

The  lateral  borders  correspond  with  the  interstices  of  the  two 
peritoneal  folds,  anterior  and  posterior,  which,  as  they  leave  the 
uterus,  form  the  broad  hgaments.  They  are  continuous  with  those 
of  the  vagina.  Both  are  in  immediate  relation  with  the  numerous 
vessels  which  enter  these  two  organs.  The  lower  extremity  projects 
into  the  cavity  of  the  vagina,  which  encircles  it.  It  is  a  little  lower 
before  than  behind,  and  the  posterior  utero-vaginal  cul-de-sac  has 
in    consequence  a  greater   depth  than  the    anterior  one   (Fig.  18). 

*  Sappey,  Anat.  descript,  t.  iii,  p.  661.  Paris,  1864  ;  Comte,  Bulletin  de  la 
Societe  anatomique,  1826,  t.  i,  p.  49. 


20  INTRODUCTION 

This  extremity^  often  incorrectly  designated  as  the  neck,  is  the  vaginal 
portion  of  the  neck  (Fig.  15).  Normally  it  looks  downwards  and 
backwards,  and  this  direction  may  be  exaggerated  to  such  an  extent 
that  the  axis  of  the  neck  may  form  a  right  angle  with  the  vagina,  its 
vaginal  portion  resting  on  the  posterior  wall  of  this  membranous  canal. 
Sometimes  it  hardly  projects ;  at  other  times  it  does  so  considerably ; 
on  an  average  it  is  from  10  to  12  millimetres  long.  Its  slightly 
rounded  form  may  be  flattened,  or,  on  the  contrary,  be  elongated  till 
it  becomes  conical. 

A  transverse  orifice  divides  it  into  two  lips,  united  right  and  left 
by  thick  commissures.  The  projection  and  size  of  these  lips  are  un- 
equal. The  anterior  is  the  more  prominent,  the  lower  and  the  easier 
to  find,  owing  to  the  cervix  being  directed  backwards ;  the  posterior, 
however,  has  a  larger  surface  on  account  of  the  vaginal  insertion  being 
higher  behind  than  before.  This  circumstance,  added  to  the  difPerence 
in  length  of  the  two  walls  of  the  vagina  (the  posterior  being  the 
longer),  should  remind  us  to  pass  the  finger  or  sound  along  the  pos- 
terior wall  in  order  to  make  sure  of  reaching  the  cervix  (Mg.  18). 


Ligaments  and  Appendages  of  the  Uterus 

The  study  of  these  ligaments  is  very  important  from  a  double 
point  of  view,  whether  we  consider  them  as  a  means  of  suspension 
of  the  uterus,  or  whether  we  study  the  consequences  resulting 
from  the  partitioning  produced  by  their  presence  in  the  pelvic 
excavation. 

I.  Means  of  suspension. — They  are  of  two  kinds :  some  suspend 
the  uterus  by  its  fundus  and  by  its  sides,  others  by  its  neck.^ 

The  former  are  the  broad  ligaments  and  the  round  ligaments ;  the 
latter  are  the  utero-sacral  ligaments  and  the  suspensory  ring. 

A.  1.  The  broad  ligaments  are  the  two  lateral  parts  of  the  double 
peritoneal  fold  which,  continued  from  the  bladder  to  the  uterus  to  be 
reflected  afterwards  from  the  uterus  to  the  rectum,  contains  within 
its  folds  the  uterus  in  the  centre  with  its  appendages  on  either  side 
and  divides  the  pelvis  into  two  unequal  parts,  the  one  anterior,  vesical, 
the  other  posterior,  recto-intestinal.  Commencing  from  the  lateral 
margins  of  the  uterus,  they  become  continuous  with  the  peritoneum 
which  covers  the  brim  and  pelvic  cavity,  and  are  reflected  below  before 
touching  the  floor  of  the  pelvis,  the  anterior  fold  towards  the  bladder, 
the  posterior  lower  down  on  to  the  utero-sacral  ligaments,  whilst  above 
they  are  subdivided  into  three  secondary  folds,  the  anterior  containing 
the  round  ligament,  the  middle  the  Pallopian  tube,  and  the  posterior 
the  ovary  and  its  ligament  (Figs.  1,  20).  They  are  not  formed  merely 
by  a  fold  of  peritoneum,  for  this  serous  membrane  is  lined  throughout 
their  whole  extent  with  a  muscular  layer,  to  which  I  shall  call  atten- 

'  See  Fig.  20,  p.  22,  where  tbese  ligaments  are  represented  in  a  newly  born 
child,  seen  from  before  ;  and  Fig.  1,  front,  where  they  are  seen  from  behind  in 
an  adult. 


ANATOMY,   PHYSIOLOGY  AND    TEEATOLOGY 


21 


tion  in  describing  the  contractile  organs  of  the  uterus.     Apart^  how- 
ever, from  their  contractility  they  may  be  said  to  contribute  in  main- 


PiG.  19. —  Horizontal  section  of  the  pelvis  of  a  woman,  aged  twenty  (after 
Le  Gendre).  The  section,  which  is  made  at  1  cm.  above  the  pubis,  passes 
through  the  ilium  about  the  middle  of  the  coxo-femoral  articulation,  on  a 
level  with  the  upper  borders  of  the  bladder  and  uterus,  the  fundus  of  the 
latter  being  divided.  The  bladder  is  but  slightly  distended,  the  rectum 
is  pushed  a  little  to  the  right  of  the  sacrum  and  enveloped  by  the  peri- 
toneum, except  the  portion  which  is  adherent  to  this  bone.  The  uterus  on 
its  posterior  surface  is  in  contact  with  the  bladder.  It  presents  a  deviation 
from  its  normal  position,  as  is  often  observed  on  the  cadaver.  The 
fundus,  which  is  strongly  inclined  to  the  left  instead  of  to  the  right  as  is 
usual,  fits  into  the  cotyloid  cavity  of  the  same  side ;  the  deviation  is  such 
that  the  body  of  the  utenis  occupies  all  the  left  side  of  the  true  pelvis. 
Besides  this  lateral  deviation  there  is  a  considerable  anteflexion  of  the 
body.  The  distance  which  separates  the  anterior  surface  of  the  uterus 
from  the  abdominal  wall  is  about  7  cm.  In  the  right  side  of  the  pelvic 
cavity  are  seen  the  uterine  appendages  in  their  normal  order  of  super- 
position ;  the  round  ligament  with  the  Fallopian  tube  below,  and  quite 
behind  and  to  the  outer  side  the  ovary.  N,  peritoneum  ;  A,  upper  border 
of  the  bladder ;  B,  angle  of  union  of  the  fundus  with  the  neck  of  the 
uterus ;  M,  fundus  of  the  uterus,  divided  ;  H,  right  ovary  ;  i,  round 
ligament  ;  J,  Fallopian  tube  ;  L,  broad  ligament  of  the  right  side  ;  K, 
fibrous  tissue  between  the  rectum  and  fundus  uteri ;  c,  rectum  ;  n,  meso- 
rectum  ;  T>,  sacrum ;  E,  head  of  the  femur ;  g,  cotyloid  cavity  ;  E,  fibrous 
capsule  of  the  coxo-femoral  articulation ;  o,  femoral  vein ;  p,  femoral 
artery ;  a,  crural  nerve ;  b,  epigastric  artery  and  vein ;  c,  c,  lymphatic 
ganglia  ;  i,  inguinal  canal ;  Q,  sciatic  nerve  ;  I,  gluteal  vessels  ;  F,  gluteus 
maximus ;  s,  8,  gluteus  medius ;  T,  gluteus  minimus  ;  it,  v,  s,  t,  z,  fascia 
lata,  sartorius,  right  rectus,  iliacus  and  psoas  muscles  ;  d,  pyramidalis 
muscle  ;  e,  rectus  abdominis  muscle  ;  /,  internal  oblique  muscle ;  g,  ob- 
turator internus  muscle  ;  h,  levator  ani  muscle  ;  j,  sacro-sciatic  ligament ; 
K,  superior  gemellus  muscle ;  m,  aponeurosis  of  the  external  oblique 
muscle. 

taining  the  uterus  in  position  ;  when  they  are  cut  in  the  dead  body 
the  uterus  is  seen  to  obey  the  laws  of  gravity,  and  to  incline  to  the 
side  towards  which  the  pelvis  inclines,  whilst  it  reassumes  its  proper 


22  INTEODUCTION 

place   as  soon  as  their  continuity  is  once  more  effected  by  means  of  a 


Fig.  20. — General  view  of    the   internal   genital  organs  of    a  child  at  birth. 

1,  bladder  with  the  urachus  above  and  on  each  side  the  umbilical  arteiies  ; 

2,  2,  round  ligaments  ;  3,  body  of  the  uterus  bent  forwards  ;  4,  4,  Fallopian 
tubes  ;  5,  5,  ovaries,  above  which  is  seen  on  each  side  an  ascending  longi- 
tudinal projection  of  peritoneum,  near  Douglas's  fold,  formed  by  the 
ovarian  vessels  and  the  superior  round  ligament,  which  raises  the  serous 
membrane ;  6,  6,  Douglas's  peritoneal  folds  covering  the  utero-lumbar 
ligaments  ;  7,  rectum.  This  woodcut  is  intended  to  show  all  the  means  of 
suspension  of  the  uterus,  including  the  broad  ligaments  and  the  superficial 
muscular  layer  lining  them,  a  common  envelope  embracing  the  womb  and 
its  appendages,  and  connecting  them  simultaneously  with  the  anterior, 
posterior,  and  lateral  portions  of  the  pelvis.  It  shows  at  the  same  time 
the  position  and  form  of  these  organs  peculiar  to  the  foetus  and  infant. 

suture.^     Repeated  pregnancies,  together  with  other  causes,  produce 
considerable  relaxation  in  these  organs. 

2.  The  round  ligaments,  originating  in  smooth  muscular  fibres  from 
the  whole  extent  of  the  sides   of  the  womb,  and  especially  from  its 
'  Sappey,  Traite  d'anaiomie,  t.  iii,  p.  651.    Paris,  1864. 


ANAT0M7,    PHYSIOLOGY    AND    TERATOLOGY  23 

upper  half,  pass  off  from  its  lateral  angles  or  from  the  extremities  of 
the  fundus  in  front  of  and  a  little  below  the  Fallopian  tubes,  are  en- 
veloped on  each  side  by  the  anterior  fold  of  the  broad  ligament,  reach, 
at  their  outer  extremity,  the  brim  of  the  pelvis,  and  from  there,  being 
deflected  inwards,  the  abdominal  orifice  of  the  inguinal  canal,  having 
traversed  which,  they  are  inserted  by  some  of  their  fibres  into  its  inferior 
wall,  by  others  into  the  spine  of  the  pubis,  and  by  others,  again,  into  the 
upper  part  of  the  labia  majora.  They  evidently  contribute  to  maintain 
the  fundus  of  the  uterus  in  a  forward  position ;  if  too  short,  they  may 
determine  anteversion  or  anteflexion  ;  if  too  long,  they  let  the  uterus 
fall  or  become  retroflexed ;  if  unequal,  they  may  favour  lateral  flexion 
(Fig.  20). 

B.  The  means  of  suspension  of  the  cervix  are  more  certain  and  more 
resistant  than  those  of  the  body.  They  consist  of  the  posterior  liga- 
ments and  the  anterior  adhesions  of  the  uterus  to  the  bladder. 

1.  The  posterior  ligaments  arise  from  the  sides  of  the  posterior 
surface  of  the  uterus  at  the  union  of  the  body  and  neck,  or  rather  at 
the  point  where  the  vagina  is  inserted,  and  are  formed  of  muscular 
fibres  which  are  continuous  with  those  of  the  organ  itself  and  pass 
under  the  posterior  layer  of  the  broad  ligament.  Covered  by  the  peri- 
toneum, which  being  reflected  from  the  broad  ligament  above  them  to 
descend  from  there  into  the  utero-rectal  cul-de-sac  forms  in  this  manner 
the  fold  of  Douglas,  they  pass  outwards  to  be  inserted  immediately  to 
the  inside  of  the  sacro-iliac  symphysis  at  the  third  sacral  vertebra,  and 
often  above  as  far  as  the  promontory  or  the  anterior  and  lateral  part  of 
the  last  lumbar  vertebra,  which  has  led  Huguier'  to  designate  them  as 
utero-lmnhar  in  place  of  utero-sacral  ligaments.  It  is  these  ligaments 
which  prevent  the  cervix  from  descending,  even  in  the  majority  of 
raultiparse,  unless  gentle  but  sustained  traction  is  made  on  the  two 
lips. 

2.  The  anterior  adhesions  of  the  uterus  to  the  bladder  (Fig.  18) 
are  not  less  important  as  means  of  suspension.  These  adhesions 
evidently  prevent  the  cervix,  if  not  from  falling  or  from  being  dragged 
forwards  towards  the  pubis  in  cases  where  the  utero-sacral  liga- 
ments are  relaxed  or  torn,  at  least  from  inclining  backwards  towards 
the  sacrum ;  for  even  when  the  bladder  is  distended  by  urine,  as  its 
base  is  only  moderately  developed,  the  uterus,  in  place  of  being  pushed 
back  as  a  whole  towards  the  sacrum,  is  raised,  and  its  fundus  which 
looked  forwards  is  directed  upwards  and  then  backwards  and  some- 
times even  it  may  be  completely  retroverted  towards  the  sacrum. 

As  the  result  of  these  two  means  of  suspension  (Douglases  ligaments 
embracing  the  posterior  and  upper  part  of  the  cervix,  and  the  adhesions 
with  the  bladder  the  anterior  and  upper  partj  the  cervix  may  be 
said  to  be  suspended  by  two  half  rings ;  the  one  posterior,  preventing 
it  from  inclining  forwards  and  downwards ;  the  other  anterior,  pre- 
venting it  from  inclining  backwards,  which  complement  each  other 
and  form  a  real  suspensory  ring  which  maintains  the  upper  third  of 
the  cervix  in  a  sufficiently  fixed  position  in  the  pelvic  cavity  (Figs.  1, 
'  Allongements  hypertrophiques  du  col,  p.  80.    Pnris,  1859. 


24  IKTEODUGTION 

18) .  At  the  same  time  it  results  from  the  point  of  attachment  of  this 
double  half  ring  that  the  free  portion  of  the  cervix,  below  and  the 
whole  body  above  may  oscillate  and,  under  the  influence  of  various 
kinds  of  pressure,  incUne  in  different  directions  without  the  portion  of 
the  cervix  embraced  by  this  ring  leaving  the  centre  of  the  pelvis.  The 
uterus  cannot  descend  unless  the  posterior  half  ring  is  relaxed ;  it  cannot 
rise  unless  the  anterior  half  ring  is  stretched;  but  it  may  oscillate  in 
all  directions  round  this  double  half  ring  as  round  a  suspensory  ring. 
We  cannot  judge  better  of  the  nature,  direction  and  extent  of  these 
movements  than  by  provoking  them  by  means  of  the  finger  introduced 
into  the  vagina  :  in  pushing  the  cervix  backwards  we  perceive  that  the 
body  is  directed  forwards;  in  pushing  it  to  the  right  the  fundus  is 
directed  to  the  leftj  and  vice  versa  ;  in  other  words,  the  fundus  by  a 
swinging  motion  is  always  directed  in  the  opposite  direction  from  the 
cervix. 

II.  Division  of  the  pelvic  cavity. — The  ligaments  are  not  less  im- 
portant as  regards  the  divisions  which  they  establish  in  the  pelvic 
cavity  than  as  means  of  suspension.  The  vast  folds  which  have  just 
been  described  under  the  name  of  broad  ligaments  divide  the  pelvis 
proper  into  two  unequal  compartments  :  the  one  anterior,  occupied  in 
great  part  by  the  bladder ;  the  other  posterior,  containing  the  rectum 
and  the  utero-vagino- rectal  cavity.  So  that  whilst  the  uterus  at  the 
brim  is  connected  with  the  bladder  in  front,  behind  it  is  separated 
from  the  rectum  by  a  large  cavity.  This,  which  may  be  called  the 
utero  vaginu-reclal  cavity,  is  very  deep,  especially  in  multiparse.  When 
no  adhesion  limits  its  extent,  either  from  before  backwards  from  the 
vagina  to  the  rectum,  or  from  one  side  to  another  between  and  below 
the  folds  of  Douglas,  this  cavity  may  attain  great  dimensions ;  for  the 
dimensions  are  those  of  the  pelvic  cavity  itself,  exclusive  of  the  thick- 
ness of  the  rectum,  vagina  and  bladder,  which  occupy  very  little 
space  in  a  state  of  vacuity.  I  have  often  measured  this  cavity  in 
various  directions,  the  antero-posterior,  and  even  the  transverse 
diameter,  may  exceed  eight  centimetres  if  the  folds  of  Douglas  are 
stretched ;  if  they  are  left  in  their  natural  position  there  may  be  a 
space  of  five  or  six  centimetres  between  them ;  as  to  the  depth  of  the 
cavity,  from  the  upper  border  of  the  uterus  to  the  bottom  of  the  vagino- 
rectal  cul-de-sac  there  is  from  fifteen  to  eighteen  centimetres  j  taken 
below  the  utero-sacral  ligaments  it  measures  from  five  to  nine  centi- 
metres. Into  this  cavity  the  small  intestine  may  descend  in  a  state  of 
health,  in  various  diseases  the  ovary  may  be  dragged  there  by  its  own 
weight,  and  in  extreme  retroflexions  the  fundus  of  the  uterus  may  fall 
even  below  the  ligaments  of  Douglas ;  and  lastly,  it  is  there  that 
sanguineous,  serous  and  purulent  effusions  are  formed,  and  that  fibri- 
nous adhesions  take  place  in  hematoceles  and  retro-uterine  peritonitis. 

To  the  right  and  left  of  the  bladder  are  superficial  fossae ;  to  the  right 
and  left  of  the  retro-uterine  cavity,  behind  the  ligaments  of  the  ovary 
and  above  the  folds  of  Douglas,  are  two  deeper  and  more  extensive 
fospse,  where  tubo-ovarian  and  uterine  adliesions  are  often  formed  after 
inflammations  of  the  ovary  and  Fallopian  tubes.     Secondary   longi- 


ANATOMY,    PHYSIOLOGY    AND   TERATOLOGY 


25\ 


tudinal  fossse,  or  rather  grooves,  separate  the  upper  margins  of  the 
small  folds  and  are  also  frequently  the  seat  of  inflammatory  sero- 
purulent  adhesions  and  efl^usions.  It  is  useless  to  describe  the  relations 
of  these  peritoneal  surfaces  with  the  abdomino-pelvic  viscera,  or  the 


\ 


Fig.  21. — -Relations  of  the  viscera  contained  in  the  female  pelvic  cavity  (after 
Tillaux).  L  F,  ligament  of  the  Fallopian  tube  ;  L  o,  ligament  of  the 
ovary  ;  L  E,  round  ligament  ;  E,  rectum  ;  s,  sacrum  ;  s  p,  symphysis  pubis  ; 
u,  uterus  ;  v  s,  utero-sacral  ligament ;  v,  bladder. 

continuity  of  this  peritoneal  covering  with  that  of  the  ihac  fossa,  Fal- 
lopian ligament,  &c.  It  is  important,  however,  to  remember  them  in 
order  to  account  for  the  extension  of  inflammation  to  various  points 
not  only  of  the  retro-uterine  peritoneal  cavity  but  also  of  the  iliac 
and  hypogastric  portions  of  the  peritoneum,  which  may  be  affected  by- 
suppuration,  or  may  give  rise  to  a  purulent  collection  contained  within 
septa  of  new  formation.  It  is  also  important  to  remember  that  these 
broad  ligaments  contain  a  more  or  less  abundant  and  dense  cellular 
tissue  within  their  folds  in  addition  to  the  muscular  tissue  lining 
them. 

Their  two  smooth  surfaces  are  in  relation,  the  anterior  with  the 


26 


INTRODUCTION 


bladder,  the  posterior  with  the  rectum ;  it  is  at  right  angles  from  the 
latter  that  the  two  folds  of  Douglas  arise,  which  cover  the  utero-sacral 
ligaments.  There  are  four  borders — superior,  inferior,  internal,  and  ex- 
ternal. The  superior  is  subdivided  into  three  small  folds.  Tine  inferior 
is  in  relation  with  the  subperitoneal  cellular  tissue  of  the  pelvis  and 


M.U 


Fig.  22. — Section  of  the  uterus  aud  broad  ligaments  perpendicular  to  the 
large  axis  of  the  womb  at  2  centimetres  from  its  base  (after  Tillaux). 
B,  pelvic  wall  ;  cu,  uterine  cavity ;  ll,  broad  ligament ;  MU,  uterine 
mucous  membrane  ;  P,  P,  peritoneum  ;  TU,  uterine  tissue ;  vu,  utero- 
ovarian  veins. 

with  the  superior  perineal  aponeurosis.  The  internal  is  very  wide 
(Fig.  22),  the  two  folds  being  separated  from  each  other  by  the  thicic- 
ness  of  the  uterus ;  it  is  in  relation  with  the  uterine  artery  and  the 
utero-ovarian  plexuses,  venous  and  lymphatic  ;  it  is  continuous  with  the 
inferior  border  on  the  lateral  portions  of  the  vagina  (Fig.  28,  l  s  p), 
having  the  same  relations  with  the  veins  and  lymphatics,  and  allowing 
of  the  recognition  by  vaginal  touch  of  phlebitis,  lymphangitis,  tumours 
and  purulent  collections  formed  in  this  ligament.  The  external  is  in 
relation  with  the  walls  of  the  cavity ;  it  is  very  thin,  the  two  folds  of 
peritoneum  being  in  close  proximity  ;  a  horizontal  section  of  the  broad 
ligaments  and  of  the  uterus  at  about  an  inch  from  its  base  shows  very 
clearly  the  difference  in  thickness  of  the  two  borders  (Fig.  22). 

The  cellular  tissue  with  which  this  vast  peritoneal  fold  is  lined  is 
loose  and  abundant,  especially  below  where  it  is  continuous  with  the 
cellular  tissue  covering  the  upper  perineal  aponeuroses  and  levator  ani 
(Fig.  23)  and  with  that  which  covers  the  lateral  surfaces  of  the 
bladder,  the  peritoneal  lining  of  the  abdominal  wall  at  the  hypogas- 
trium  and  of  the  internal  iliac  fossa.  Consequently  an  inflammation 
of  the  broad  ligament  may  be  propagated  in  any  of  these  various 
regions,  or  an  abscess  of  this  ligament  may  open  into  the  vagina, 
bladder,  rectum,  into  the  ischio-rectal  fossa,  at  the  top  of  the  sacro- 
sciatic  groove,  or  may  appear  at  the  hip  with  the  sacral  plexus  and  the 
sciatic  nerve  or  may  reach  the  abdominal  wall  on  a  level  with  the  Fallo- 
pian ligament,  above  or  below  the  crural  arch  or  even  at  the  obturator 
foramen.  Pelvi-peritonitis  is  most  frequently  posterior  (retro-uterine 
cavity) ;  it  may  be  anterior  or  it  may  surround  the  uterus  on  all  sides 


ANATOMY,    PHYSIOLOGY    AND    TEEATOLOGY 


27 


rising  to  a  greater  or  less  height^  to  the  brim  or  even  above  the  cavity, 
according  to  the  height  of  the  adhesions  or  new  membranes  which 
limit  it,  and  may  open  into  the  rectum,  into  a  part  of  the  intestine, 
the  sigmoid  flexure  or  even  the  csecum,  or  at  the  abdominal  wall  above 
the  crural  arch,  on  a  level  with  the  hernial  fossse.  Abscess  of  the 
broad  ligament  is  lateral,  on  one  or  other  side  of  the  uterus  and 
vagina,  pushing  back  these  organs  towards  the  opposite  side  without 


Fig.  23. — Transverse  section  of  the  pelvis,  showing  the  three  cavities  (after 
Beigel).  1.  cp,  peritoneal  cavity  ;  2.  lsp,  sub-peritoneal  space  ;  3.  esc,  sub- 
cutaneous space  ;  v,  vagina  ;  na,  levator  ani ;  p,  peritoneum  ;  u,  uterus. 

extending  all  round,  and  making  an  exit  for  itself  by  all  the  communi- 
cations which  may  be  established  from  the  pelvic  cellular  tissue  through 
the  natural  orifices  to  outside  the  pelvis,  at  the  iliac  fossa,  hip, 
thigh,  &c. 

Thus  the  broad  ligaments,  besides  being  a  means  of  suspension  for 
the  uterus,  are  of  capital  importance  in  the  physiological  and  patho- 
logical history  of  this  organ,  of  its  appendages,  and  of  the  peri- uterine 
regions ;  they  give  the  key  to  the  difl'erential  diagnosis  of  hematoceles, 
pelvi-peritonitis,  peri-uterine  phlegmons,  abscesses  of  the  broad  liga- 
ments, phlebitis,  peri-uterine  angioleucitis  and  adenites  of  the  same 
region,  both  in  a  puerperal  and  non-puerperal  condition.  They  cannot 
be  too  much  studied  or  too  well  known. 


28 


INTRODUCTION 


Changes  in  the  Uterus  at  Different  Ages    ' 

In  the  genital  organs  of  women^  and  especially  in  the  uterus,  the 
volume,  form,  external  aspect,  cavities,  structure,  all  the  anatomical 
conditions  in  fact,  vary  from  age  to  age. 

External  aspect. — The  size  of  the  organ,  which  is  small  in  the  foetus 
and  chUd,  increases  considerably  at  puberty,  as  do  all  other  parts  of 
the  generative  system  :  but  it  is  very  inferior  in  the  nullipara  to  what 
it  is  in  the  multipara,  and  it  diminishes  in  old  age  under  the  influence 
of  the  retrogression  and  atrophy  which  follow  the  menopause. 

The  form,  which  is  almost  cylindrical  in  the  fcetus,  gradually 
assumes  the  aspect  peculiar  to  it,  in  proportion  as  the  body  undergoes 
its  normal  development :  so  that  at  puberty  in  the  nullipara,  but  espe- 
cially in  the  multipara,  the  resemblance  of  the  uterus  to  a  small 
inverted  gourd  becomes  very  striking.  Its  position,  direction,  and 
relations  change  also  with  age  on  account  of  the  difference  of  develop- 
ment which  exists  from  one  period  of  life  to  the  other,  not  only  between 
the  various  parts  of  the  genital  organs,  but  also  between  those  of  the 
pelvis.  The  pelvic  cavity  being  but  slightly  developed  in  childhood, 
the  uterus,  like  the  bladder,  is  higher  above  the  brim  at  this  age  than 
in  the  adult,  and  is  generally  inclined,  and  even  curved,  forwards 
(Figs.  I,  28). 


Fig.  24. — The  uterus  and  its  appendages  in  the  fcetus  at  the  end  of  the  fourth 
month,  natural  size.  A,  external  view  :  a,  a,  ovai'ies  relatively  voluminous, 
almost  as  long  as  the  Fallopian  tubes  ;  b,  h,  oviducts  ;  c,  c,  round  ligaments  ; 
d,  uterus  ;  e,  vagina  ;  /,  vaginal  orifice.  B,  cavities  :  a,  branches  of  the 
arbm-  vita  extending  to  the  fundus ;  b,  vaginal  portion  of  the  uterus  ; 
c,  vagina. 

It  is,  however,  especially  in  the  antagonism  of  the  hody  and  neck  that 
the  most  remarkable  differences  are  to  be  seen  from  one  age  to 
another. 

In  the  child  the  neck  is  very  large,  the  body  very  small.  The  neck 
is  almost  cylindrical.  The  body  is  triangular,  more  flattened  than  in 
the  adult;  its  superior  border  is  straight  or  slightly  concave,  a  vestige 
of  the  coalescence  of  the  uterine  cornua;  its  lower  extremity  is  con- 
tinuous with  the  neck  without  any  hne  of  demarcation.  The  isthmus 
is  indicated  at  this  age  less  by  a  contraction  than  by  a  change  of  direc- 


ANATOMY,    PHYSIOLOGY,    AND   TERATOLOGY 


29 


tion  between  the  neck  and  the  body ;  for  the  result  of  Boullard's  i 
researches,  confirmed  by  my  own  observations,  is  that  there  is  very 


-=-^-^=^A 


Fig    95  —  Uterus    at   the  commencement   of    the  seventh  month,  opened,  of 
'natural  size,     a,  fundus  with  thin  walls;   fc  &,  orifices  of    the  Fallopian 
tubes  ;   c,  arbor  vitse  ;  d,  neck,  remarkable  for  the  relative  thickness  of  its 
walls. 

frequently,  if  not  always,  anteflexion  of  the  body  on  the  cervix.     (Fig. 
28.)     In  the  girl  at  puberty,  and  still  more  in  the  adult,  the  body  is 


Fig.  26. 


Fig.  26. — Utems  at  birth,  natural  size  ;  external  view,  a,  body  ;  h,  neck,  very 
large,  rendered  clearly  distinct  from  the  body  by  the  formation  of  the 
isthmus  ;  c,  vaginal  portion  of  the  neck  ;  d,  d,  Fallopian  tubes  ;  e,  e,  round 
ligaments.  Cavities  :  h,  cavity  of  the  body  showing  the  arbor  vitee.  The 
fundus  a  and  the  walls  are  relatively  thin  ;  c,  neck,  the  walls  of  which 
are  very  thick  ;  d,  vaginal  portion  of  the  cervix  ;  e,  vagina. 

Fig.  27. — Section  of  uterus  at  seventh  year,  open,  of  natural  size,  a,  fundus ; 
6,  body,  the  cavity  of  which  still  shows  a  trace  of  the  internal  longitudinal 
fold  resulting  from  the  union  of  the  two  primitive  uteri,  and  forming  a 
continuation  of  the  arbor  vitse  of  the  neck ;  c,  neck  still  longer  than  the 
body  and  with  thicker  walls  ;  d,  vaginal  portion  of  the  neck  ;  e,  vagina. 

developed  more  than  the  neck,  and  becomes  slightly  curved,  especially 
behind.  The  upper  border  is  often  straight,  sometimes  even  it  is 
almost  convex ;  its  union  with  the  neck  is  well  marked  by  an  isthmus. 
The  neck,  in  place  of  remaining  cylindrical,  has  assumed  the  form  of  a 

'  Quelques  mots  sur  I'uterus.    Theses  de  Paris,  1853,  No.  87. 


30 


INTRODUCTION 


small  barrel,  contracted  above,  tapering  below,  and  is  shorter.  The 
anterior  flexion  of  the  body  on  the  neck  diminishes,  according  to 
Cusco,^  in  consequence  of  the  unequal  development,  which  being 
greater  on  the  anterior  than  on  the  posterior  surface,  helps  to  straighten 
the  organ.  Still,  a  slight  degree  of  anteflexion  or  rather  inclination 
forwards  often  continues,  not  only  in  the  girl  after  puberty,  but  in  the 
married  woman,  provided  she  has  never  been  pregnant. 

In  the  nullipara  the  characteristics  of  virginity  remain,  with  the 
exception  of  a  slight  increase  in  the  size  of  the  whole  of  the  organ, 
caused  doubtless  by  the  exercise  of  a  new  function.  We  may  also 
admit  some  difference  in  the  vaginal  portion  of  the  neck  :  it  often  loses 
its  slightly  conical  shape,  and  becomes  rather  flattened.  The  cases  in 
which  the  neck  is  normal  must  be  distinguished  from  those  in  which  it 
is  quite  conical.  In  the  latter  cases  coitus  does  not  modify  the  conicity 


Fig.  28. — Uterus  of  a  foetus  at  birth,  side  view  seen  in  its  relations,  showing 
the  normal  anteflexion  natural  during  foetal  and  infantile  life  (after 
Boullard  and  Bourgery).  a,  body  of  the  uterus  flexed  forwards  ;  &,  fundus 
of  body  looking  forwards  ;  c,  neck,  relatively  very  large  ;  d,  section  of  the 
peritoneum ;  e,  cervix  ;  /,  vagina  ;  g,  hymen  ;  I,  Fallopian  tube,  behind 
which  the  ovary  is  seen  ;  j,  bladder ;  h,  rectum  ;  n,  symphysis  pubis. 

in  the  least ;  on  the  contrary,  it  persists  and  is  even  increased  to  a 
certain  extent,  owing  to  the  penis  being  apt  to  pass  below  the  neck 
and  so  increase  the  depth  of  the  posterior  utero- vaginal  cul  de-sac,  and 
is  one  of  the  most  unmistakable  causes  of  sterility. 

In  cases  where  the  cervix  is  of  normal  shape,  the  pressure  deter- 
mined by  the  penis  during  coitus  is  made  on  this  organ,  and  gradually 
diminishes  the  convexity  so  as  shghtly  to  flatten  it  and  render  the  two 


1  De  V anteflexion  et  de  la  retroflexion  de  Vuterus.    These  de  concours,  pp.  18, 
21.    Paris,  1853. 


ANATOMY,   PHYSIOLOGY   AND    TERATOLOGY 


31 


lips  more  distinct.  These  characters  are  very  nearly  those  of  Roe- 
derer's -^  ulerus  virgineus. 

In  the  primipara,  and  still  more  in  the  multipara,  the  body  is  much 
larger  than  the  neck ;  besides  increasing  in  size  it  changes  in  form 
and  becomes  convex  in  every  direction,  especially  at  its  superior  border. 
Generally  it  becomes  quite  straight,  sometimes,  on  the  contrary,  the 
flexion  increases.  In  this  case,  however,  the  flexion  is  not  exclusively 
forwards ;  it  may  be  backwards  or  to  one  side,  according  to  the  direc- 
tion in  which  the  determining  cause  has  acted  on  a  uterus  in  which  the 
consistency  may  have  been  diminished,  whilst  the  size  has  been  in- 
creased by  pregnancy  and  parturition. 

In  old  women  atrophy  of  the  organ  takes  place.  This  is  more 
active  in  the  body  than  in  the  neck,  restoring  in  some  degree  the  rela- 
tive proportion  of  these  two  parts  to  what  it  was  in  the  child,  or  at 
least  before  the  period  of  sexual  activity.     Like  Cruveilhier,^  I  have 


Fig.  29. 


Fig.  30. 


Fig.  29. — Mould  of  the  uterine  cavities  in  a  virgin  of  seventeen  years, 
c,  cornua  of  the  uterus,  ceratine  portion  of  the  body ;  cb,  inferior  segment 
of  the  body  ;  ha,  isthmus  ;  ad,  neck,  with  impression  of  the  folds  of  the 
arhor  vitce  and  the  lateral  depression  of  the  column,  t,  Fallopian  tubes, 
slight  contraction  at  the  point  of  union  of  their  cavity  with  that  of  the 
body  (after  Guyon). 

Fig.  30. — Mould  of  the  uterine  cavities  in  a  multipara,  triangular  form  of  the 
cavity  of  the  body,  enlargement  and  deformity  of  the  uterine  cornua, 
enlargement  of  the  inferior  segment  of  the  body  which  blends  with  them. 
ab,  isthmus  ;    ad,  neck,  with  double  depression  (after  Guyon). 

remarked  that  the  obhteration  of  the  vaginal  portion  of  the  neck  is 
very  common. 

Internal  conformation. — The  cavities  of  the  uterus  are  very  small, 
but  they  still  differ  considerably  in  their  size  and  form  in  the  child,  the 


1  Icones  uteri  humani. 

-  Anat.  descript.,  t.  ii,  p.  474. 


Paris,  1866. 


32  INTRODUCTION 

nullipara  and  multipara.  They  form  together  a  sort  of  canal  flattened 
from  before  backwards,  constricted  at  the  isthmus  and  widening  out  in 
the  body  as  it  approaches  the  fundus.  According  to  Sappej,i  their 
length  is : 

In  the  nullipara  about  52  millimetres,  the  body  measuring  22,  the 
neck  25,  the  isthmus  5. 

In  the  multipara  about  57  millimetres,  the  body  measuring  28,  the 
neck  24,  the  isthmus  5. 

I  think  these  measurements  rather  exaggerated,  especially  that  of 
the  body  in  the  multipara  when  there  is  no  disease.  Apart  from  this, 
the  difference  in  the  relative  length  of  the  body  and  neck,  the  latter  of 
which  is  the  greater  in  the  nullipara  and  the  former  in  the  multipara,  is 
in  harmony  with  the  difference  in  size  of  the  two  parts  seen  externally 
(Eigs.  29,  30,  34,  35).  The  other  two  dimensions  are  very  small, 
especially  the  distance  separating  the  anterior  from  the  posterior 
surface.  On  this  account  it  is  very  difficult  to  move  the  sound  in 
either  direction. 

The  cavity  of  the  body,  which  hardly  exists  in  the  foetus,  becomes 
triangular  after  puberty.  The  walls  are  flat,  and  applied  one  against 
the  other,  unless  a  little  mucus  is  interposed  between  them.  The 
borders  are  convex,  and  are  directed  towards  each  other  in  such  a  way 
that  the  convergence  of  their  convexity  towards  the  centre  diminishes 
to  an  equal  extent  the  uterine  cavity.  Therefore  a  slightly  curved 
sound  when  introduced  into  this  cavity  cannot  easily  be  moved  from 
one  side  to  the  other,  still  less  be  rotated  upon  itself.  The  superior 
angles,  very  acute,  present  the  last  folds  of  the  mucous  membrane  of 
the  Fallopian  tubes,  and  it  is  the  very  close  proximity  of  these  folds 
which  forms  the  only  obstacle  to  the  passage  of  a  fluid  from  the  cavity 
of  the  body  into  that  of  the  Fallopian  tubes.  The  inferior  angle, 
less  acute,  corresponds  with  the  os  internum.  In  the  multipara 
the  cavity  of  the  body  is  distinguished  by  different  characters — 
greater  capacity  and  an  interval  between  the  two  surfaces,  or  at 
least  the  possibiKty  of  separating  them  and  of  moving  the  sound 
between  them ;  superior  angles  less  acute.  The  form  is  triangular,  but 
the  margins  are  very  seldom  convex,  sometimes  they  are  straight,  often 
concave,  hence  the  marked  increase  of  the  cavity  circumscribed  by 
them.  This  latter  tendency  seems  to  be  more  marked  when  the 
number  of  pregnancies  has  been  considerable,  and  when  they  have 
occurred  in  quick  succession. 

The  cervical  cavity,  large  in  the  child,  is  fusiform,  flattened  from 
before  backwards,  presenting  consequently  two  walls,  two  borders  and 
two  orifices.  The  walls  are  unequal,  traversed  from  top  to  bottom  by 
a  vertical  projection,  from  which  secondary  oblique  and  ascending 
projections  are  given  off,  an  arrangement  which  has  received  the  name 
of  arbor  vita.  (Figs.  29,  32,  35,  38).  The  posterior  tree  only  becomes 
visible  a  few  millimetres  above  the  inferior  orifice ;  it  increases  in  size, 
and  deviates  to  the  left  in  proportion  as  it  approaches  the  superior 
orifice.  The  anterior  tree  is,  on  tlie  contrary,  directed  towards  the  right. 
'  Op.  cit.,  p.  664 


ANATOMY,    PHYSIOLOGY   AND    TERATOLOGY 


33 


Consequently  the  two  cervical  walls  fit  into  each  other  in  place  of  one 
being  applied  one  against  the  other^  as  in  the  cavity  of  the  body. 
These  kind  of  columns  are  analogous  to  the  columnse  carnese  of  the 


Tig.  31. — Transvei-se  sections  taken  from  the  upper  half  of  the  cervix,  showing 
the  dovetailing  of  its  walls,  especially  of  the  two  longitudinal  projections, 
which  may  be  said  to  be  the  trunks  of  the  arhor  vitce,  and  consequently 
the  mechanism  for  the  occlusion  of  the  isthmus  or  os  internutn  (after 
Guyon) .  1,  virgin  uterus  at  sixteen  years  old  ;  2,  uterus  in  a  nullipara  ; 
3,  uterus  in  a  multipara.  Exceptionally  there  are  two  posterior  projections, 
but  only  one  anterior  and  median. 

heart.  It  is  to  Guyon  ^  that  we  owe  the  knowledge  of  their  fitting 
into  each  other,  and  of  several  other  facts  relative  to  the  study  of  the 
uterine  cavities. 

The  OS  internum  is  a  true  strait  of  5  millimetres  in  length,  in  which 
the  arbor  vitse,  stripped  of  their  branches,  dovetail  into  each  other  so 
well  that,  owing  to  the  narrowness  of  the  orifice,  they  fill  it  entirely 
and  make  it  difficult  for  the  sound  to  enter ;  but  this  resistance  over- 
come, it  enters  easily  into  the  cavity.  The  sensibility  of  this  orifice  and 
the  circular  arrangement  of  the  bundles  of  muscles  which  form  a  veri- 
table sphincter  at  this  point,  in  addition  to  the  narrowness  of  the 
opening  and  the  dovetailing  of  the  posterior  and  anterior  columns, 
increase  the  difficulties  experienced,  in  the  case  of  certain  morbid  con- 
ditions or  of  virgins,  in  passing  the  sound  from  the  cavity  of  the  neck 
into  that  of  the  body  (Figs.  29,  35).  At  other  times,  on  the  contrary, 
as  the  result  of  other  morbid  conditions,  nothing  is  easier  than  to  pass 
through  this  orifice  (Fig.  32).  As  a  rule,  a  catheter  of  2  milli- 
metres in  diameter  will  enter  it.  After  the  menopause  the  os  internum 
gradually  contracts,  and  in  some  women  is  at  last  obliterated. 

The  OS  externum  is  broader,  though  occasionally  it  is  rounded  and 
narrow.  This  narrowness  may  be  more  or  less  marked,  even  reach- 
ing the  degree  at  which  it  is  known  as  atresia,  which  is  really  im- 
perforation  or  obliteration.  Then  the  retention  of  mucus  or  of 
menstrual  blood  increases  the  capacities  of  the  cavities,  as  may  be 
seen  in  the  accompanying  figure  taken  from  Guyon  (Fig.  32  eh, 
ad).  Often,  too,  in  such  a  case  the  projection  of  the  uterus  into 
the  vagina  is  conical,  and  the  orifice  may  be  at  the  summit  of  this 
cone  or  on  one  of  its  sides  a  little  in  front  or  a  little  behind.  Gene- 
rally, however,  it  is  in  the  form  of  a  slit,  on  which,  in  the  foetus  and 
infant,  we  can  see  the  starting-point  of  the  trunks  of  the  arhor  vita, 
which  gives  to  this  opening  a  form  somewhat  similar  to  that  of  the 

•  Etude  sur  les  cavites  de  I'uterus  a  I'etat  de  vaeuile.  Theses  de  Paris,  1858. 
Hagemann  {ArcJiivfilr  Gynecologic,  Bd.  v,  p.  295)  has  arrived  at  the  same  results. 

3 


34 


INTEODUCTIOX 


mouth  (Guyon).  These  projections  are  effaced  with  age  so  as  to 
reduce  the  orifice  to  a  straight  line^  the  margins  of  which  are  iu  contact 
in  the  child  and  adult  nullipara.     The  latter  differs  from  the  former  in 


Fig.  32. — Mould  of  the  uteiine  cavities  in  a  nuUipai-a  foi-tj-two  years  of  age. 
There  "n-as  a  Tvell-marked  contraction  of  the  os  externum.  Its  form  is  the 
same  as  that  of  the  nteras  in  the  virgin  (Fig.  29),  but  the  comua  are 
broader,  the  cervico-nterine  isthmus  is  dilated,  the  upper  segment  of  the 
body  and  the  cervical  cavity  are  more  developed  (after  Guyon) . 

the  slight  flattening  of  the  cervix,  the  lips  of  which  seem  to  allow  the 
orifice  to  open  more  easily.  In  the  multipara  the  slit  is  open,  irregular, 

1  2 


Fig.  33. — Differences  in  the  vaginal  poi-tions  of  the  cervix  in  the  nullipara,  1 ; 
and  in  the  multipara,  2. 

and  indented  by  cicatrices  consequent  on  lacerations  caused  at  de- 
livery. To  sum  up,  there  are  differences  in  the  uterus  of  a  nuUipara 
and  that  of  a  multipara  which  should  prevent  their  being  confounded. 
1st.  Externally,  the  uterus  of  the  multipara  is  less  fixed,  it  has  a 
less  elevated  position  and  a  more  marked  variability  of  inclination  than 
the  uterus  of  a  nullipara.  Its  two  surfaces  and  its  upper  border  are 
rounded.  The  vaginal  portion  of  the  neck  is  less  conical  and  less 
elongated.    The  orifice  is  longer,  the  lips  irregular  and  indented,  open- 


ANATOMY,    PHYSIOLOGY   AND    TERATOLOGY 


35 


ing  easily  and  allowing  the  entrance  of  the  point  of  the  finger.     The 
uterus  is  larger ;  all  its  diameters  have  increased,  especially  the  longi- 


FiG.  34. — Differences  in  the  external  conformation  o£  the  uterus  in  a  nullipara, 
1  ;  and  in  a  multipara,  2  (after  Dubois). 

tudinal  one.     The  increase  of  size,  and  especially  of  length,  is  shown 

J2 


Fig.  35. — Differences  in  form  and  size  of  the  uterine  cavities.     The  nullipara 
1 ;  and  the  multipara,  2  (after  Dubois) . 

more  in  the  body  than  in  the  neck.     The  walls  of  the  organ  have 
acquired  a  greater  thickness. 

2nd.  Internally y  the  cavity  of  the  body  is  increased  and  has  changed 
in  shape :  its  borders,  in  place  of  being  convex,  have  become  concave. 
The  superior  angles  are  no  longer  funnel-shaped.  The  openings  of  the 
Fallopian  tubes  are  broader.  The  cavity  of  the  neck  is  proportionally 
shorter  and  rather  broader.    The  os  internum  is  more  open,  and  allows 


36  INTEODUOTION 

the  sound  to  penetrate  more  easily.  The  axis  of  the  two  cavities  is 
less  frequently  curved  forwards^  and  when  it  is  curved  either  forwards, 
backwards,  or  to  one  side,  it  is  more  easily  rectified  by  the  introduc- 
tion of  an  instrument,  unless  there  are  adhesions  or  some  morbid 
condition. 


Steucture  op  the  Uterus 

The  structure  of  the  uterus  is  not  analogous  to  that  of  any  other 
organ.  The  walls  are  thick,  but  not  equally  so  throughout.  Hardly 
exceeding  8  millimetres  at  the  opening  of  the  Fallopian  tubes,  they  are 
as  a  rule,  according  to  Sappey,^  10  millimetres  thick  at  the  fundus  and 
from  12  to  15  anteriorly  and  posteriorly  and  at  the  lateral  borders. 

1.  Its  arteries  are  the  ovarian  from  the  aorta  and  the  uterine  from 
the  internal  iliac,  without  counting  those  of  the  round  ligaments  arising 
from  the  epigastric.  They  enter  the  uterus  by  its  borders,  not  without 
anastomosing  considerably,  describing  numerous  flexuosities  and  cork- 
screw windings,  which  have  led  to  their  being  compared  to  the  helicine 
arteries  of  the  erectile  tissues  generally  and  of  the  cavernous  bodies  of 
the  penis  in  particular. 

3.  Its  veins,  which  are  voluminous  and  almost  without  valves, 
anastomose  largely  and  are  adherent  to  the  tissue  of  the  organ,  forming 
during  pregnancy  dilatations  known  as  sinuses.  They  emerge  along 
the  lateral  borders  and  form  two  vast  plexuses  contained  in  the  folds  of 
the  broad  ligaments  and,  without  joining  the  veins  of  these  ligaments 
which  flow  into  the  epigastric  or  external  iliac,  they  empty  themselves, 
some  into  the  internal  iliac,  others  into  the  vena  cava  on  the  right  and 
the  renal  vein  on  the  left,  being  marked  during  the  whole  length  of 
their  course  by  a  plexus  analogous  to  the  pampiniform  plexus  in  man. 

3.  Its  lymphatic  vessels,  studied  especially  during  pregnancy  or  after 
delivery  by  Mascagni,  Cruveilhier  and  others,  have  lately  been  investi- 
gated by  Leopold^  in  the  unimpregnated  uterus  in  woman,  as  well  as  in 
the  female  mammalia,  and  by  Lucas  Championnierc^  in  the  uterus  after 
delivery.  Whether  they  arise  from  the  mucous  membrane  or  from  the 
muscular  wall,  the  hypertrophy  of  which  they  share  in  pregnancy,  these 
lymphatic  vessels  are  divided,  like  the  veins,  into  two  principal  groups 
on  each  side ;  the  inferior,  which  come  from  the  cervix,  open  into  the 
lateral  pelvic  glands;  the  superior  into  the  lumbar  ganglia.  Cham- 
pionniere  has  discovered  that  the  lymphatics  of  the  cervix  unite  in 
vessels  of  various  sizes  at  the  union  of  the  body  and  cervix ;  generally 
there  is  one  much  larger  than  the  others ;  they  emerge  at  this  level 
into  the  lateral  cellular  tissue  at  the  base  of  the  broad  ligaments  fol- 
lowing the  course  of  the  blood-vessels  and  at  once  join  one  or  two 
little  ganglia  which  are  not  constant  but  which,  when  wanting,  are 
replaced  by  a  lymphatic  network  which  forms  a  real  and  important 

'  Op.  cit.,  p.  665. 

2  ArcMvfur  Gynecologie,  Bd.  vi,  p.  1.    Berlin,  1873. 

3  Lymphatiriues  uterins  ei  Lymphavgite  uterine.     Paris,  1870. 


ANATOMY,    PHYSIOLOGY  AND  TEllATOLOGY  37 

vascular  plexus.  The  largest  at  last  reach  the  posterior  subperitoneal 
surface  of  the  broad  ligamentj  and  from  there  pass  to  the  deep  pelvic 
and  sacral  ganglia,  sometimes  even  reaching  an  inguinal  and  obturator 
ganglion. 

The  lymphatics  of  the  body  arise  chiefly  from  the  portion  which 
adjoins  the  placental  surface  ;  they  anastomose  with  those  of  the 
ovaries  and  Fallopian  tubes  and,  following  the  utero-ovarian  venous 
plexus,  they  accompany  these  vessels  to  the  vascular  plexuses  and 
lumbar  ganglia  where  they  end.  It  is  impossible  to  attach  too  much 
importance  to  the  exact  knowledge  of  the  lymphatics  of  the  uterus  and 
its  appendages.  In  the  sites  indicated  by  anatomists  I  have  frequently 
observed,  kernels  of  inflammatory  induration,  which  could  be  nothing 
else  than  retro-uterine  adenitis,  and  this  opinion  has  occasionally  been 
confirmed  by  autopsies.  I  am  more  and  more  convinced  every  day  of 
the  important  part  played  by  angioleucitis,  adenitis  and  even  peri- 
uterine adenomata,  not  only  in  the  history  of  uterine  and  peri-uterine 
phlegmasia  in  puerperal  maladies,  but  in  a  number  of  others  accom- 
panied by  deep  and  continuous  pain,  which  otherwise  would  be 
inexplicable. 

4.  The  nerves  of  the  uterus  and  ovaries,  according  to  Tranken- 
hauser,  arise  directly  and  indirectly  from  the  coeliac  plexus  through 
the  intervention  of  the  renal  plexus  which,  through  its  inferior  gan- 
glion, is  distributed  to  the  ovaries  and  spermatic  ganglia.  The  aortic 
plexus  by  its  upper  part  (superior  mesenteric  plexus)  suppHes  these 
spermatic  ganglia,  which  would  be  more  correctly  designated  genital 
ganglia.  These  ganglia,  four  in  number,  receive  two  large  branches 
from  the  great  sympathetic  and  give  ufi"  a  great  number  of  nerves  to 
the  ovaries.  Below  the  origin  of  the  inferior  mesenteric  artery  is  the 
great  uterine  plexus  (lumbo-aortic),  which  descends  to  1  centimetre 
from  the  division  of  the  aorta  and  is  formed  of  the  principal  branches 
of  the  genital  ganglia  with  the  addition  of  small  branches  proceeding 
from  the  four  lumbar  ganglia  of  the  great  sympathetic.  On  the  pro- 
montory it  is  divided  into  hypogastric  plexuses,  which  are  joined  by 
branches  from  the  terminal  ganglia  of  the  sympathetic  and  are  situated 
behind  the  rectum,  on  the  inner  side  of  the  pelvic  vessels,  and  are  dis- 
tributed to  the  lateral  borders  of  the  cervix  uteri.  Each  hypogastric 
plexus  measures  from  7  to  10  centimetres,  and  in  its  course  supplies 
branches  to  the  mesorectum,  to  the  mesentery  of  the  sigmoid  flexure, 
and  to  the  ureter.  There  is  a  large  cervical  ganglion  on  each  side  of 
the  neck,  easily  discovered  in  the  newly-born  even  without  prepara- 
tion, but  covered  in  adults  by  the  pelvic  fascia  and  superimposed 
nerves.  It  extends  downwards  as  far  as  the  folds  of  Douglas,  and 
measures,  in  the  empty  uterus,  about  2  centimetres  in  length  and  1  in 
breadth,  and  during  pregnancy  5  centimetres  in  length  and  2  or 
3  in  breadth.  The  greater  number  of  the  uterine  nerves  arise  from 
these  two  ganglia,  the  rest  coming  directly  from  the  hypogastric 
plexus.  The  cervico-uterine  ganglia  receive  their  afferent  branches 
not  only  from  the  hypogastric  plexuses,  but  also  from  the  second,  third 
and  fourth  sacral  pairs.     They  supply  branches  not  only  to  the  uterus 


38  INTEODUCTION 

but  also  to  the  vagina,  bladder  and  rectum.  Besides  tliese  principal 
ganglia  there  are  on  each  side  two  small  ones  for  the  urethra  and  bladder, 
the  latter  sending  some  branches  to  the  anterior  surface  of  the  uterus. 
The  nervous  branches  from  the  cervico-uterine  ganglia  enter  the  cervix 
horizontally ;  passing  upwards  they  pierce  the  inferior  portion  of  the 
body  obliquely,  whilst  above,  along  the  borders  of  the  uterus,  they  run 
almost  vertically,  uniting  with  each  other  in  the  thickness  of  the  ante- 
rior and  posterior  walls  ;  they  also  anastomose  with  the  ovarian  nerves. 
The  ramifications  of  the  uterine  nerves  may  be  traced  as  far  as  the 
mucous  membrane  in  the  neck,  but  this  cannot  be  done  in  the  case  of 
the  body.  Erankenhaiiser  has  found  motor  fibres  in  the  uterine 
plexus  but  he  has  not  been  able  to  discover  sensory  fibres.  It  seems 
impossible  to  distinguish  the  filaments  arising  from  the  cerebro-spinal 
and  ganglionic  systems. 

5.  The  serous  envelope  of  the  uterus  is  nothing  else  than  the  peri- 
toneum, which,  being  reflected  from  the  posterior  surface  of  the 
bladder  to  the  anterior  surface  of  the  body  of  the  womb,  covers  all 
tlie  posterior  surface  of  the  fundus  including  the  nech  and  the  upper 
part  of  the  posterior  vaginal  wall  and  extends  right  and  left  over  the 
broad  ligaments. 

6.  The  uterine  mucous  memhrane  was  for  a  long  time  unknown.  It 
was  Coste^  who  demonstrated  at  the  same  time  its  existence,  its  struc- 
ture and  its  hypertrophy  into  the  decidua  during  pregnancy.  I 
helped  to  make  this  discovery  known  and  to  develop  it  twenty  years 
ago.^  Since  then  Robin  has  described  the  histology  of  this  membrane,^ 
and  other  writers  have  studied  the  formation  of  the  decidua  and  the 
regeneration  of  the  uterine  mucous  membrane.^ 

The  mucous  membrane  of  the  uterus  is  different  in  the  body  and  in 
the  neck. 

In  the  body  it  is  attenuated  toward  the  angles,  where  it  is  con- 
tinuous with  that  of  the  neck  and  of  the  Pallopian  tubes.  It  is 
thickest  towards  the  centre,  varying  from  3  to  6  millimetres, 
according  to  Coste.     The  free  surface  is  smooth,  without  wrinkles, 

1  Memoire  sur  la  formation  de  la  caduque  dans  I'ceuf  humain.  Comptes 
rendus  des  seances  de  I'Academie  des  Sciences  de  Paris,  t.  xv,  1842,  and  t.  xxiv, 
1847.     Traite  general  du  develojopement.     Paris,  1848. 

2  De  I'ceuf  et  de  son  develojppement  dans  I'espece  humaine,  p.  127.  Montpellier, 
1845. 

3  Cli.  Robin,  Memoire  poiir  servir  a  I'histoire  anatomique  et  patliologique  de 
la  memhrane  imiqueuse  uterine,  de  son  mucus  et  des  oeufs,  ou  inieux  glandes  de 
Naboth,  see  Archives  generales  de  medecine,  t.  xvii  and  xviii.     Paris,  1848. 

^  Colin,  Mtude  a  I'ceil  nu  sur  la  surface  interne  de  I'uterus  apres  V accoiiche- 
ment  dans  I'etat  physiologique,  dans  V etat  patliologique,  et  en  particulier  dans 
la  fievre  puerperale.  Theses  de  Paris,  1847,  No.  229  ;  see  also  A.  Richard,  De 
la  muqueuse  uterine.  Paris,  1848  ;  Ch.  Robin,  Memoire  sur  les  modifications 
de  la  Tnuqueuse  uterine  pendant  et  apres  la  grossesse  ;  see  Memoires  de  I'Aca- 
demie de  medecine,  t.  xxv,  p.  81,  Paris,  1861 ;  Ercolani,  Delia  struttura  della 
caduca  uterina,  Bologna,  1874  ;  Leopold,  Studien  iiber  die  Uterusschleimhant 
ivahrend  Menstruation,  Schwangerschaft  u.  Wochenbett ;  the  paper  is  accom- 
panied by  a  larj^e  number  of  figures  representing  sections  of  the  miicous 
membrane  magnified  in  these  various  states.  Archiv  filr  Gyncecologie,  Bd.  xi, 
pp.  110,  443,  &c.     Berlin,  1877. 


ANATOMY,    PHYSIOLOGY    AND    TERATOLOGY 


39 


papillse  or  villosities,  but  perforated  with  a  multitude  of  orifices  which 
are  the  mouths  of  as  many  follicles  or  tubular  glands,  and  covered 


Fig.  37. 

Fig.  36. — Internal  mucous  membrane  of  a  uterus,  the  anterior  wall  of  which 
has  been  partially  removed  (after  Coste).  p  p,  tissue  proper,  in  which 
numerous  vascular  orifices  are  seen,  resulting  from  section  of  the  vessels ; 
vi  m,  mucous  membrane,  the  regularly  striated  appearance  of  which  is 
remarkable,  as  well  as  its  rose  colour.  The  little  vermicular  body  placed 
below  the  uterus  is  a  small  gland  ;  t,  initial  extremity,  ending  in  cul-de- 
sac  ;  0,  terminal  extremity,  presenting  a  narrow  orifice  opening  upon  the 
internal  surface  of  the  uterine  cavity. 

Fig.  37. — General  view  of  the  glands  or  flexuous  follicles  of  the  uterine  mucous 
membrane,  ddd,  simple  or  double  cul-de-sac  of  these  follicles  ;  a  aa,  thin 
cup-shaped  orifice  opening  on  to  the  surface  of  the  mucous  membrane. 

with  conical  cells  of  from  3  to  4  hundredths  of  a  millimetre,  with 
pyramidal  base  furnished  with  vibratile  cilia  smaller  than  the  vibratile 
epithelium  cells  of  the  Fallopian  tubes  which  are  not  less  than  7 
hundredths  of  a  millimetre.  This  epithelium,  vibratile  in  the  empty 
uterus,  becomes  tesselated  during  gestation,  when  the  mucous  mem- 
brane becomes  the  decidua.  The  tubular  glands,  shghtly  flexuous 
and  cylindrical,  adhere  by  their  blind  end  which  is  sometimes  bifid  to 
the  subjacent  tissue ;  they  open  on  the  surface  of  the  mucous  mem- 
brane into  a  little  cup  surrounded  by  a  kind  of  vascular  polygon,  and 
are  lined  with  nucleated  epithelium.  Their  diameter  is  about  equal  to  i 
the  twelfth  part  of  their  length,  and  the  space  separating  them  is  i 
about  equal  to  their  diameter.  They  participate  in  the  general  hyper- 
trophy of  the  organ  during  pregnancy.  The  tissue  between  the 
follicles  is  formed  of  occasional  fibrous  bundles  (cellular,  laminar  or 
connective  tissue),  of  fibro-plastic  elements,  esneciallv  of  nuclei,  cells. 


40  INTEODUCTION 

fusiform  bodies  aud  of  a  great  deal  of  granular  amorphous  matter. 
( Thus  the  framework  of  the  membrane  is  in  the  embryonic  state  and 
!  in  every  stage  of  development.  The  uterus  is  the  only  organ  in  which 
i  we  constantly  find  a  tissue  in  process  of  organisation.  This  pecu- 
liarity is  in  direct  relation  with  the  modifications  in  size  and  structure 
which  are  necessitated  by  the  fulfilment  of  its  functions ;  it  determines 
at  the  same  time  a  special  direction  for  its  morbid  processes ;  it 
explains  several  obscure  points  in  its  pathology ;  it  helps  also  in  the 
search  after  therapeutical  remedies  and  may  explain  the  occasional 
unexpected  effects  produced  by  them.  At  the  menstrual  period  the 
mucous  membrane  greatly  increases  in  thickness,  it  becomes  congested 
and  remains  gorged  with  blood  till  the  hsemorrhage  is  established,  or 
rather  till  it  has  ceased.  Its  surface  is  pufi'ed  out  and  furrowed  with 
wrinkles  which  resemble  the  cerebral  circumvolutions.  The  glands 
participate  in  this  congestion  which  is  almost  a  temporary  hyper- 
trophy. Their  secretion,  generally  insignificant,  becomes  consider- 
able, especially  before  and  after  the  hsemorrhage. 

In  the  tieck  the  mucous  membrane  is  very  adherent  as  in  the  body, 
but  it  is  thinner,  having  a  thickness  of  only  1  or  2  millimetres ;  it 
is  wrinkled,  lined  with  ciliated  epithelium  formed  of  a  subsirakim 
analogous  to  that  of  the  mucous  membrane  of  the  body,  and  in  which 
embryonic  elements,  such  as  the  fibro-plastic  fusiform  bodies,  pre- 
dominate :  lastly,  it  is  furnished  abundantly  with  secreting  organs, 
regarded  formerly  as  simple  follicles  with  ampullary  blind  ends  and 
constricted  neck,  but  lately  described  by  Sappey  as  racemose  glands 
with  two  or  three  branches  and  subdividing  to  terminate  in  a 
cul-de-sac.  These  glands  are  found  in  the  uterine  and  vaginal  orifices 
as  well  as  in  the  cavity  of  the  neck.  They  are  remarkable  for  their 
size  in  their  whole  course.  Their  orifices  are  seen  at  the  bottom  of 
the  grooves  which  separate  the  branches  of  the  arbor  vitce.  They 
secrete  a  thick  and  very  viscous  mucus,  alkaline  like  that  of  the  body, 
the  reverse  of  the  vaginal  fluid  which  is  acid.  This  mucus  in  accu- 
mulating forms  in  the  foetus,  and  often  in  the  adult,  especially  during 
pregnancy,  a  very  adherent  gelatinous  cylinder  which  fills  up  the 
cavity  of  the  neck.  These  glands  frequently  become  the  seat  of  a 
partial  or  total  dilatation,  which  transforms  them  into  a  kind  of  cyst 
known  as  Naboth's  eggs.  These  cysts,  as  they  grow,  become  em- 
bedded in  the  muscular  coat.  The  glands  of  the  neck  are  the  organs 
which  specially  produce  uterine  leucorrhoea.  Although  more  acces- 
sible than  the  follicles  of  the  body  to  our  means  of  treatment  because 
nearer  to  us,  they  are  not  any  more  amenable  to  the  action  of  the  means 
employed,  owing  to  their  position  at  the  bottom  of  the  rugged  grooves 
into  which  they  open  between  the  ramifications  of  the  arbor  vita. 
Fig.  38,  taken  from  Tyler  Smith,^  gives  an  idea  of  the  difficulty  there 
is  in  reaching  them.  __ 

The  muscular  envelope,  or  what  has  been  called  the  tissue  proper 
of  the  uterus  is  very  complicated.      Super-position  of  deep  layers, 
intersection  of  superficial  bundles,  a  vascular  development  peculiar  to 
'  On  Pathology  and  Treatment  of  Leucorrhcea,  p.  25.     Londou,  1855. 


ANATOMY,    PHYSIOLOGY    AND    TERATOLOGY 

erectile  organs,  all  contribute  in  giving  this  organ  a  texture  rendered 
more  difficult  of   description   by  the   fact   that  till  now  anatomists 


Fig.  38. — General  view  of  the  transverse  or  oblique  ramifications  of  one  of  tte 
two  median  columns  of  the  mucous  membrane  which  constitute  the  anterior 
and  posterior  arhores  vita  in  the  cervical  canal  of  a  virgin,  magnified 
nine  diameters. 

have  hardly  taken  into  account  the  facts  gathered  from  development, 
from  comparative  anatomy  and  from  the  musculo-vascular  conditions 
of  erectility  which  alone  could  throw  any  light  on  this  study.  At 
present  we  know  the  structure  of  the  uterine  tissue,  the  elements 
which  enter  into  its  composition,  the  wealth  and  special  arrangement 
of  its  blood-vessels,  and  the  super-position  and  the  mutual  relations 
of  the  majority  of  the  muscular  bundles  which  characterise  the  texture 
of  the  womb. 

The  essential  elements  of  the  tissue  of  the  uterus  are  smooth  mus- 


J.  INTEODUOTION 

cular  fibres,  incorrectly  called  fibre-cells,  muscular  fibres  of  organic 
life  characterised  by  the  presence  of  a  nucleus  not  exceeding  7  hun- 
dredths of  a  millimetre  in  length  and  5  thousandths  of  a  millimetre  in 
width  in  the  unimpregnated  uterus,  but  attaining,  during  gestation, 
ten  times  the  length  and  five  times  the  width  and  allowing  of  the  pene- 
tration of  a  few  fatty  granulations.  The  hypertrophy  of  the  organ 
during  pregnancy  does  not  consist  merely  in  the  increased  size  of  the 
elements  already  existing ;  there  is  also  a  formation  of  new  muscular 
elements  and,  in  addition  to  the  growth  of  contractile  fibres,  is  added 
that  of  the  fibrous  or  connective  tissue  which  joins  them  together. 


Fig.  39. — Smooth  muscular  fibres  of  tlie 
Tinimpregnated  uterus  (after  Farre). 


Fig.  40. — Fibre-cells  of  the  utenis 
in  state  of  gestation  (after 
"Wagner). 


After  delivery  atrophy  brings  these  elements  back  to  their  normal 
condition.  This  peculiarity  characterises  the  muscular  membrane  of 
the  uterus  as  well  as  its  mucous  membrane.     If  the  muscular  tissue 


Fig.  41. — Progress  of  involution  or  disintegration  and  rene-R-al  of  uterine  fibres 
after  delivery.     Process  of  fatty  degeneration  (after  Hescbl). 

has  not,  like  the  mucous  membrane,  the  faculty  of  development  carried 
to  the  point  of  renewal,  it  is  always,  like  the  latter,  to  a  certain  extent 
in  process  of  development,  and  consequently  has  the  characteristic  of 
anatomical  instability,  this  forming  a  striking  contrast  to  the  stability 
of  all  other  organs.  This  special  property  of  the  uterine  tissue  plays 
an  important  part  in  the  development  of  its  diseases,  imprints  a  special 


ANAT03JT,    PHTSIOLOGT   AND    TERATOLOGY  43 

character  on  its  pathology  and  exercises  a  marked  influence  on  its 
therapeutics. 

It  IS  now  agreed  that  the  contractile  bundles  are  composed  of  three 
layers  of  elementary  fibres.  The  deep  layer  is  formed  of  two  orbicular 
muscles  arranged  in  concentric  curves,  which  converge  right  and  left 
around  the  orifice  of  the  Fallopian  tubes  as  a  central  point,  and  to  which 
Ruysch  gave  the  name  of  detrusor  placenta,  attributing  to  them  the 
function  of  loosening  the  placenta.  At  the  isthmus  which  unites  the 
cavity  of  the  body  with  that  of  the  neck  this  layer  is  formed  of  simple 
circular  bundles,  intersecting  at  acute  angles  and  constituting  a  con- 
strictor, the  presence  of  which  accounts  for  the  occlusion  of  the 
uterus  during  gestation  and  explains  its  tendency  to  contract  at  this 
point  like  a  sphincter,  the  difficulty  often  experienced  in  passing  the 
sound,  and  the  difference  between  the  resistance  presented  by  this 
orifice  and  the  dilatability  of  the  os  externum  and  cervical  cavity 
either  during  pregnancy  or  in  certain  morbid  conditions,  and  lastly,  the 
frequent  obliteration  of  the  os  internum  after  the  menopause. 

Hehe's^  recent  researches  have  confirmed  the  truth  of  this  descrip- 
tion. The  central  layer  seems  to  be  the  thickest  and  most  inextricable. 
According  to  Pajot-  it  is  composed  principally  (in  the  upper  regions  of 
the  anterior  and  posterior  surfaces  where  it  can  be  studied)  of  muscular 
bands  in  loops  which  cover  one  another.  The  superficial  layer,  on  the 
contrary,  is  most  easily  studied  in  the  unimpregnated  uterus,  especially 
in  children.  As  Puouget  has  observed,  these  organs  preserve  the  traces 
of  the  primitive  forms  till  puberty,  the -uterine  cornua  are  still  distin- 
guishable under  the  thin  muscular  layer  which  covers  them,  the  tissue 
proper  of  the  uterus  is  only  slightly  developed,  the  connections  of 
the  superficial  layers  with  neighbouring  membranes  are  more  marked, 
and  these  membranes  themselves  are  thin,  transparent  and  free  from 
the  adipose  tissue  which  afterwards  invades  them,  and  thus  present  them- 
selves to  the  observer  under  the  most  favorable  conditions  for  study. 

The  right  and  left  segments  of  the  uterus  have  doubtless,  like  the 
Fallopian  tubes,  longitudinal  fibres  and  layers  of  circular  fibres  which 
are  a  continuation  of  those  of  the  oviducts.  In  addition,  however,  to 
these  special  fibres,  which  are  found  in  much  greater  number  on  the 
two  lateral  halves  of  this  organ  than  on  the  Fallopian  tubes,  there  are 
doubtless  common  fibres  which  complete  the  fusion  of  these  two  halves 
in  order  to  make  one  central  organ  having  one  cavity.  Above  these 
muscular  layers  there  is  a  common  envelope,  also  muscular,  forming  a 
broad  contractile  apparatus,  uniting  the  movements  of  the  womb  with 
those  of  the  Fallopian  tubes,  ovaries,  broad  ligaments,  round  ligaments 
and  ligament  of  the  ovarian  vessels,  i.e.  with  the  so-called  uterine 
appendages. 

If  we  spread  the  genital  organs  of  a  child  on  a  piece  of  glass,  it  is 

1  Journal  de  la  section  de  medecine  de  la  Societe  academique  du  departement 
de  la  Loire-Inferieiire,  t.  Ix,  p.  125.  Nantes,  1864.  Becherches  surla  disposi- 
tion des  fibres  musculaires  de  I'uterus  developpe  par  la  grossesse,  avec  un  atlas 
de  dix  planches.    Paris,  1865. 

2  Dubois  et  Pajot,  Traite  complet  de  I'art  des  accouche^nents,  p.  437.  Paris, 
1860. 


44 


INTRODUCTION 


easy  to  observe  that  in  the  human  species,  as  in  the  mammalia,  the 
uterus  and  its  appendages  are  contained  in  the  thickness  of  a  broad 
muscular  membrane;  to  which  the  peritoneal  hgaments  are  only  sub- 
sidiary. It  is  easy  to  follow  the  continuity  of  the  muscular  bundles 
of  this  membrane  with  the  upper  layer  of  the  uterine  tissue  so  well 
described  by  Deville.^ 


Fig.  42. — G-eneral  view  of  the  vascular  structures  of  the  internal  genital  organs 
in  woman,  in  their  relations  with  the  superficial  muscular  system  (after 
Eouget).  The  vagina,  uteras  and  appendages  are  seen  from  behind. 
Vascular  system, — b,  bulb  communicating  on  the  one  side  with  the  spongy 
tissue  of  the  clitoris,  and  on  the  other  with  the  venous  plexus  of  tlie 
vagina ;  PV,  semi-circular  enlargement  of  the  vaginal  venous  plexus ;  PC, 
cervico-uterine  plexus  ;  pit,  uterine  plexus  ;  SP,  helicine  arteries  of  the 
body  of  the  uterus ;  h,  heliciae  arteiies  of  the  hilum  of  the  ovary.  Mus- 
cular stractures  :  vp,  insertion  of  the  muscular  bundles  of  the  vagina  into 
the  pubis ;  vs,  bundles  of  fibres  of  the  same  muscular  layer  from  the 
region  of  the  sacro-iliac  symphysis  ;  rs,  bundles  of  iiterine  muscular  fibres 
accompanying  the  preceding,  and  constituting  in  great  part  the  posterior 
fold  of  the  broad  ligaments ;  rn,  retro-uterine  ligaments ;  Li,  inguinal 
or  pubic  round  ligaments  spreading  over  the  whole  anterior  surface  of  the 
uterus  ;  LO,  ligament  of  the  ovary ;  LS,  superior  or  lumbar  round  liga- 
ment which  accompanies  and  envelopes  the  ovarian  vessels  ;  a,  bundles  of 
muscular  fibres  from  the  ligament  of  the  ovary  LO,  spreading  over  and 
interlacing  with  bundles  of  fibres  b,  from  the  lumbar  ligament  LS, 
within  the  thickness  of  the  ovary  and  beyond  in  the  fold  of  the  Fallopian 
tube  before  their  attachment  to  this  tube  and  to  the  fimbriated  extremity  ;  a', 
bundles  of  fibres  from  the  ovary,  forming,  with  those  coming  directly  from 
the  superior  ligament,  the  tubo-ovarian  fringe. 


^  See  Cazeaux,  Traite  theorique  et  pratique  swr  I'Art  des  Accouchenients, 
p,  108,  3id  edit.    Paris,  1850. 


ANATOMY,    PHYSIOLOGY  AND    TERATOLOGY  45 

Eouget^  set  out  with  the  double  fact  that  the  superficial  muscular 
tunic  of  the  hollow  viscera  does  not  always  by  any  means  mould  itself 
exactly  on  their  form  and  dimensions,  and  that  the  muscles  of  organic 
life  at  their  terminal  extremity  are  constantly  in  connexion  with  some 
portion  of  the  locomotor  economy  of  animal  life,  bones,  tendons, 
aponeurosis  and  even  muscles.  He  then  studied  the  arrange- 
ment of  the  superficial  contractile  envelope  of  the  genital  organs  in 
the  vertebrate  animals  as  well  as  in  woman.  He  succeeded  in  this  way 
in  demonstrating  that  the  broad  ligaments  are  not  a  simple  fold  of 
peritoneum,  but  an  expansion  of  the  lateral  portions  of  the  uterus,  or 
rather  of  the  subjacent  muscular  folds,  with  the  serous  folds  adhering 
to  them  very  closely,  and  made  up  of  bundles  of  smooth  fibres,  which 
interlace,  forming  a  network.  The  central  portion  of  the  membrane 
formed  by  the  whole  thickness  of  these  folds  at  their  point  of  inter- 
section is  nothing  more  than  the  external  layer  of  the  muscular 
envelope  of  the  uterus.  On  the  median  line  of  the  womb  down  its 
whole  length  may  be  seen  the  decussation  of  the  muscular  bundles 
from  one  side  to  the  other  (vertical  fibres),  indicating  the  meeting  and 
crossing  of  the  two  lateral  muscular  organs  (Fig.  43).  In  this  way 
the  bundles  derived  from  the  pubic  round  ligament  (li)  spread  out 
in  the  form  of  a  fan  throughout  the  length  of  the  uterus  and  interlace 
with  those  of  the  opposite  side.  The  insertions  to  the  sacrum  and 
iliac  region  (ur,  vs,  us)  are  found  in  the  utero-sacral  ligaments 
and  the  posterior  fold  of  the  broad  ligament.  The  bundles  of  fibres 
dependent  on  the  ovarian  ligament,  mesovarium  (lo)  and  central  fold 
arise  chiefly  from  the  posterior  surface  of  the  uterus ;  the  fibres  with 
numerous  and  elongated  nuclei,  which  intermingle  in  the  stroma  of 
the  gland  and  enclose  the  Graafian  vesicles  in  the  meshes  of  their  net- 
work, are  probably  only  their  continuation.  Another  portion  of  the 
fibres  of  the  mesovarium  runs  along  the  lower  border  of  the  ovary,  and, 
having  reached  the  external  extremity,  helps  to  form  the  muscular 
cord  attaching  the  fimbriated  extremity  to  this  gland  [a').  Lastly, 
some  fibres  are  detached  from  the  upper  border  of  the  utero-ovarian 
ligament  to  mingle  with  the  muscular  groundwork  of  the  fold  of  the 
Pallopian  tube,  ending  in  this  tube  and  the  fimbriated  extremity. 

The  fibres  which  constitute  the  means  of  insertion  of  the  superficial 
muscular  envelope  of  the  uterus  at  the  lumbar  region  (superior  round 
ligament),  in  place  of  being  narrowed  into  a  band,  are  spread  out  like 
a  membrane,  envelope  the  vascular  cord  of  the  ovarian  vessels,  traverse 
it,  rise  with  it  to  the  lumbar  region,  and  are  gradually  lost  in  the 
fascia  propria,  by  means  of  which  they  are  fixed  to  the  posterior  wall 
of  the  trunk.  At  their  termination  some  of  these  fibres  radiate  into 
the  posterior  fold  of  the  broad  ligament  towards  the  uterus,  others, 
raising  the  peritoneum  in  the  form  of  a  fold,  are  deflected  outwards  on 
a  level  with  the  ovary,  and  are  attached  to  the  fimbriated  extremity 
(b),  whilst  the  greater  number,  accompanying  the  vessels  to  the  hilum 

1  Becherches  sur  les  organes  orcctiles  cle  lafemme,  et  sur  I'a^jpareil  musculaire 
tuho-ovarien,  see  Journal  de  physiologie  of  Brown-Sequard,  t.  i,  p.  203.  Paris, 
1859. 


46  I^^TEOD^CTION 

of  the  ovarVj  seem  partly  to  penetrate  into  tlie  parenchyma  of  this 
gland,  partly  to  cross  its  erectile  bulb,  and,  continuing  their  course 
into  the  fold  of  the  rallopian  tube_,  are  lost  in  the  contractile  envelope 
of  the  latter,  intermingling  with  those  which  arise  from  the  ovarian 
ligament. 

The  discovery  of  this  superficial  muscular  layer  explains  the 
mechanism  of  the  application  of  the  oviduct  to  the  ovary  at  the  moment 
of  dehiscence,  an  important  phenomenon  the  cause  of  which  was  un- 
known. The  direction  of  the  two  kinds  of  muscular  fibres  which, 
arising  from  the  lumbar  region  and  the  uterus,  embrace  the  whole 
length  of  the  TaUopian  tube  and  fimbriated  extremity  (lo,  ls,  a  h,  a'  b), 
perfectly  explains  the  movements  executed  by  these  organs  when  in- 
clining backwards  and  inwards,  the  possibility  of  the  flexion  of  the 
tube  on  itself,  and  the  application  of  the  fimbriated  end  to  the  surface 
of  the  ovary  (Tig.  42).  The  mechanism,  in  fact,  is  exactly  similar  to 
that  by  which  the  opening  of  a  bag  purse  is  closed,  the  edges  of  which 
pucker  up  when  drawn  together  by  traction  upon  the  strings  which 
pass  through  rings  attached  at  intervals  round  the  mouth  of  the  bag 
(fig.  43).  The  movements  of  the  fimbrise,  which,  so  to  speak,  sweep 
the  surface  of  the  ovary,  and  the  peristaltic  contractions  of  the  Tallopian 
tube,  receive  the  ovum  and  carry  it  to  the  uterus  (Tig.  44). 

The  movements  of  the  uterus  are  also  due  to  the  morbid  or  spas- 
modic contractions  of  this  superficial  layer  of  muscular  fibres.  Patients 
are  aware  of  this  by  the  sensations  they  sometimes  experience.     These 


Fig.  43. — Muscular  tubo-ovariaii  arrangement  in  the  rabbit  (after  Eouget). 
The  muscular  membranes  of  the  ovary  L  and  of  the  Fallopian  tube  t 
form  a  double  fold,  the  borders  of  -n-hich,  brought  together  by  muscular 
contraction,  enclose  the  ovaiy  and  fimbriae  which  are  thus  brought 
into  close  contact ;  s,  upper  round  ligament,  the  muscular  fibres  of  which 
descend  from  the  lumbar  region  towaords  the  ovaiy  and  the  fimbriated 
extremity  ;  0,  ovary  ;  r,  uterus. 

sensations  are  not  to  be  confounded  with  the  spasmodic  action  propa- 
gated to  other  organs  which  produces  such  various  effects,  e.g.  the 
globus  hystericus.  They  are  so  marked  that  we  must  admit  their 
reality  and  attribute  them  to  the  partial  or  total  contraction  of  the 
superficial  muscular  envelope.  TThen  I  add  that  this  contraction  is 
itself  the  starting  point  of  the  erection  of  the  ovary  and  uterus,  that 
these  movements  and  this  erection  are  probably  directly  connected 
with  ovulation,  menstruation  and  venereal  orgasm,  it  will  be  at  once 


ANATOMY,    PHYSIOLOGY    AND    TEEATOLOGY  47 

understood  what  importance  is  to  be  attached  to  them  in  appreciating 
the  various  impressions  experienced  by  women  and  the  subjective 
phenomena  of  uterine  diseases. 


Fig.  44. — Ovaiy  and  fimbriated  extremity  of  Fallopiaii  tube  in  a  woman  who  died 
during  menstruation  (after  Farre,  ad.  nat.).  I,  broad  ligament;  o,  ovary  ; 
r  r,  old  coi-pora  lutea,  traces  of  Graafian  vesicles  previously  ruptured  and 
cicatrised ;  /,  broad  portion  of  the  Fallopian  tube  ;  i,  fimbriated  extremity 
applied  to  the  ovaiy. 

The  tissue  proper  of  the  uterus  is  erectile  as  well  as  contractile. 
It  is  to  Eouget^  that  we  owe  the  demonstration  of  this  fact  also. 
According  to  this  observer,  every  erectile  organ  is  nothing  more  than 
a  muscular  organ  in  which  the  blood  brought  by  the  arteries  may  be 
temporarily  retained  in  the  capillaries  or  in  the  veins  transformed  into 
cavernous  sinuses  and  retiform  plexuses  ;  the  immediate  cause,  there- 
fore, of  erection  is  to  be  found  in  the  contraction  of  the  muscular 
fibres,  the  primary  element  of  all  erectile  orgasm.  He  also  observed 
in  the  branches  of  the  tubo- ovarian  arteries  an  arrangement  exactly 
similar  to  that  which  he  had  remarked  in  the  helicine  arteries  of  the 
corpus  cavernosum.  He  discovered  that  the  uterus  and  ovary  each 
possess  a  true  corpus  spongiosum  (Fig.  42),  and  that  they  may  be  the 
seat  of  phenomena  analogous  to  those  of  erection.  In  fact,  he  de- 
monstrated that,  besides  the  intrinsic  muscles  of  the  uterus  which 
may  participate  in  the  production  of  these  phenomena,  the  fibres  of  the 
tubo-ovarian  muscular  membranes  have  such  intimate  relationship  with 
the  corpora  spongiosa  of  the  uterus  and  ovary,  and  especially  with  their 
efferent  vessels,  that  at  the  moment  of  contraction  the  meshes  of  the 
network  through  which  the  veins  make  their  way  being  drawn  tighter 
in  every  direction,  the  latter  are  necessarily  compressed  and  the 
passage  of  blood  more  or  less  completely  obstructed.  The  erectility 
of  these  organs  and  the  part  that  it  plays  in  ovulation,  menstruation 
and  copulation,  can  be  proved  by  producing  an  artificial  erection  in  these 
organs  on  the  dead  body.     Normally,  the  uterus  and  ovaries  after 

^  Becker ches  sur  le  type  des  organes  genitaux  et  de  leurs  appareils  muscu- 
laires.    Inaugural  thesis.    Paris,  1855. 


48 


INTEODUCTION 


death,  if  unimpregnated,  sink  into  the  pelvic  cavity,  and  even  when 
freed  from  the  mass  of  intestines  weighing  on  them,  the  uterus,  unless 
supported  by  the  bladder  and  rectum,  yields  to  every  movement  com- 


Fia.  45. — General  view  of  the  vascular  formations  of  the  internal  genital 
organs.  PV,  semi-circiilar  enlargement  of  the  vaginal  plexus  ;  PC,  cervico- 
uterine  plexus ;  sp,  helicine  arteries  of  the  body  of  the  uteras  ;  h,  helicine 
arteries  of  the  hilum  of  the  ovary. 

municated  to  it,  bending  and  falling  when  no  longer  held  up.  In  such 
circumstances,  if,  after  having  placed  the  pelvis  in  hot  water,  we  inject 
the  ovarian  veins  till  the  corpora  spongiosa  of  the  ovary  and  uterus 
are  filled,  we  shall  see  the  body  of  the  uterus  (as  soon  as  it  is  distended 
by  the  injection)  plainly  straightening  itself  in  the  axis  of  the  neck  and 
rising  in  the  pelvic  cavity,  executing  a  movement,  that  is  to  say,  quite 
analogous  to  that  of  the  pendent  portion  of  the  penis  when  it 
straightens  itself  into  the  axis  of  the  portion  fixed  to  the  pubis  and 
rises  towards  the  abdomen.  This  change  of  position  is  accompanied 
by  a  marked  change  of  size  and  form ;  the  uterus  becomes  more  convex 
in  front,  but  especially  behind;  its  borders,  previously  attenuated 
become  round ;  and  the  walls  of  the  uterine  cavity  separate  sensibly 
at  the  same  time,  as  Gunther  and  Kobelt  have  shown  in  the  case  of 
the  walls  of  the  urethra. 

Analogous,  although  less  marked  phenomena  occur  simultaneously 
in  the  ovary,  whilst  the  Pallopian  tube  undergoes  no  change  of  any 
kind. 

As  for  the  vagina,  there  seems  to  be  no  portion  which  can  properly 
be  said  to  be  erectile,  unless  it  be  the  plexus  of  broad  veins  which 


ANATOMY,    PHYSIOLOGY    AND    TERATOLOGY  49 

runs  along  its  lateral  borders,  and  the  sometimes  circular  plexus  which 
surrounds  the  first  portion  only  of  this  canal. 

Doubtless,  as  Eouget  remarks,  sexual  excitement  in  women  is  fre- 
quently limited  to  the  erectile  structures  of  the  bulbs  and  clitoris ; 
but  when  it  is  complete — when  venereal  erethism  reaches  its  summum 
of  intensity — it  must  exceed  these  limits  and  extend  to  the  essential 
organs  of  the  genital  function,  in  which  is  then  developed  the  special 
voluptuous  sensation  which  announces  the  accomplishment  of  the 
sexual  act  which  the  organs  of  copulation  have  only  prepared. 


The  Vagina  and  Vulva 

The  vagina  is  a  membranous  canal  extending  from  the  neck  of  the 
uterus,  which  it  embraces,  to  the  vulva,  from  which  it  is  separated  by 
the  hymen  and  vulval  ring.  It  is  in  great  part  situated  in  the  pelvic 
cavity,  the  curve  of  which  it  follows  pretty  closely,  having  an  oblique 
direction  from  above  downwards  and  from  behind  forwards  which 
crosses  the  axis  of  the  perineal  strait,  so  that  its  lower  extremity  is  in 
a  plane  anterior  to  the  axis  of  this  strait.  It  forms,  therefore,  with 
the  uterus  which  is  placed  almost  in  the  direction  of  the  axis  of  the 
superior  strait,  an  angle  with  an  anterior  sinus  corresponding  to  the 
bladder  and  a  posterior  convexity  in  relation  with  the  rectum.  The  aper- 
ture of  the  angle  varies  according  to  the  vacuity  or  fulness  of  the  bladder. 
Its  length  is  from  10  to  12  centimetres,  measuring  it  from  the  vulval 
ring;  the  anterior  wall,  according  to  Sappey,  is  only  75  milli- 
metres, whilst  the  posterior  is  95  millimetres ;  its  width  varies  accord- 
ing to  the  individual,  the  age,  virginity,  pregnancy,  &c.  It  varies  also 
at  different  points,  being  narrow  at  the  vulval  orifice  and  increasing 
gradually  from  below  upwards  or  from  before  backwards  as  far  as  the 
neck  of  the  uterus.  The  dilated  portion  which  surrounds  the  cervix 
is  called  the  cul-de-sac  or  sinus,  and  is  divided  into  anterior,  posterior 
and  lateral ;  the  posterior  is  the  deepest,  and  often  conceals  morbid 
states  of  the  vagina  or  of  the  corresponding  cervical  lip  which  are 
both  difficult  to  diagnose  and  to  cure. 

When  left  to  themselves  the  anterior  and  posterior  walls  are  in  imme- 
diate contact,  so  that  in  place  of  being  cylindrical  the  vagina,  in  a  state 
of  repose,  is  really  flattened.  The  anterior  surface  is  in  relation  with 
the  urethra,  and  at  the  base  of  the  bladder  with  the  ureters  (Figs.  16, 
17,  18) ;  its  posterior  surface  with  the  perineum,  rectum,  and  with  the 
peritoneum  to  an  extent  of  from  10  to  15  millimetres  (recto-vaginal 
C7cl-de-sac) ;  its  borders  with  the  levator  ani  muscles  (which  may  com- 
bine their  action  with  that  of  the  constrictor),  with  the  perineal  or 
upper  pelvic  aponeurosis,  with  abundant  adipose  cellular  tissue,  and 
with  the  inferior  portion  of  the  broad  ligaments.  Above,  the  vagina 
adheres  to  the  neck  throughout  the  extent  of  the  central  third  of  the 
latter,  leaving  the  posterior  lip  more  exposed  than  the  anterior  and 
the  posterior  sinus  broader  than  the  anterior.  Below  it  terminates  in 
the  vulval  ring,  the  elastic  tissue  of  which,  with  the  constrictor  and  the 

4 


50 


INTEODUCTION 


bulb,  together  con'stitute  the  narrowest  part  of  the  vagina  and 
present  a  greater  obstacle  to  the  introduction  of  the  penis  than  the 
hymen,  may  offer  so  much  resistance  during  delivery  as  to  require 
incision,  and  become  the  seat  of  a  spasmodic  contraction,  with  or 
without  fissure,  similar  to  that  of  the  anus.  To  this  vulval  ring  is 
attached  the  hymen,  apparently  formed  by  the  apposition  of  the  vaginal 


Fig.  46. 


Fig.  47. 


Fig.  46. — Horizontal  section  of  soft  parts  on  a  level  with  the  inferior  strait  of 
the  vagina,  showing  its  walls  in  contact.  Va,  vagina ;  Ua,  urethra ; 
R,  rectum  and  levator  ani  (after  Cmveilhier). 

Fig.  47. — B,  anterior  vaginal  wall,  the  posterior  having  been  removed ;  Ou, 
meatus ;  above,  anterior  column  formed  by  two  enlargements  diverging 
towards  the  base  ;  Oue,  os  externum ;  *,  section  of  the  utero-vaginal  cul-de- 


mucous  membrane  (intermediary  formation)  to  the  vulval  mucous 
membrane  (external  formation),  and  which,  like  all  orifices  placed  on 
the  borders  of  two  different  embryogenic  fields,  may  be  imperforate. 
As  a  rule,  the  hymen  has  an  annular  or  semi-lunar  form  ;i  it  is  destroyed 
by  coitus,  leaving  no  other  trace  than  the  carunculie  myrtiformes.^ 

^  Roze,  De  I'hymen:  Inaugural  thesis.  Strasbourg,  1865.  We  shall  consider 
these  various  anomalies  afterwards. 

^  Puech  has  seen  the  singular  case  of  a  lady  who  never  had  a  hymen,  and 
who  after  deliveiy  had  four  carimcnlce  myrtiformes. 


ANATOMY,    PHYSIOLOGY   AND    TERATOLOGY  51 

The  internal  surface  of  the  vagina  is  remarkable  •  for  the  transverse 
ridges  of  its  mucous  membrane  known  as  rugae,  which  reach  their 
greatest  height  in  the  middle  portion,  where  they  form  on  each  wall  a 
median  projection  bearing  the  name  of  the  column,  extending  from 
top  to  bottom,  more  prominent  on  the  anterior  than  on  the  posterior 
wall  and  more  marked  near  the  vulval  orifice,  where  it  is  sometimes 
double  (Fig.  47),  than  near  the  uterine  insertion,  where  it  almost  dis- 
appears. These  columns  and  rugae,  probably  traces  of  the  double 
vagina,  give  rise  to  grooves  which  become  reservoirs  for  virulent 
matter  and  seats  of  syphilitic  or  blennorrhagic  contagion. 

The  average  thickness  of  the  vaginal  walls  is  from  3  to  4 
millimetres.  The  external  coat  is  fibro-cellular  and  thin ;  the  middle 
one  is  muscular  and  thick,  formed  of  a  superficial  layer  of  longitudinal 
fibres  inserted  below  into  the  ischio-pubic  rami,  above  into  the 
utero-sacral  ligaments  and  into  the  uterus  itself,  and  covers  a 
deep  layer  of  fibres  intercrossing  obliquely  or  circularly.  The  inner 
coat  or  mucous  membrane,  also  thick,  varying  in  colour  according  to 
age  and  reflected  above  on  to  the  vaginal  portion  of  the  cervix,  is 
furnished  with  a  great  number  of  papillae  and  covered  with  pavement 
epithelium,  which  stops  abruptly  at  the  os  externum  and  is  renewed 
throughout  the  whole  extent  of  the  mucous  membrane  with  surprising 
activity  in  certain  pathological  conditions  accompanied  by  leucorrhcea. 

It  is  remarkable  that  the  vagina  not  only  is  susceptible  of  great  expan- 
sion and  is  dilated  during  pregnancy  and  delivery,  but  that  it  positively 
hypertrophies  during  pregnancy,  its  tissues  sharing  with  those  of  the 
uterus,  though  to  a  smaller  extent,  the  property  of  alternate  hypertrophy 
and  atrophy,  in  order  to  meet  the  exigencies  of  their  special  functions. 

The  vagina  seems  to  me  to  be  without  secreting  organs  properly  so 
called.  After  having  passed  the  vulval  ring  or  circular  insertion  of  the 
hymen,  which  is  the  limit  of  the  richly  glandular  apparatus  of  the  vulva, 
we  must  reach  the  vaginal  surface  of  the  cervix  before  encountering 
new  secreting  organs.  The  fluid  which  exudes  from  the  vaginal  mucous 
membrane,  carrying  with  it  epithelial  debris,  is  always  acid.  It  not  only 
has  a  strong  acid  smell,  but  it  powerfully  reddens  litmus  paper. 

The  vulva  is  limited  externally  by  the  labia  majora,  the  cutaneous 
surface  of  which  is  covered  with  hairs  implanted  obliquely  and  the 
mucous  surface  of  which  presents  the  orifices  of  numerous  follicles,  as 
well  as  several  rows  of  sebaceous  glands.^  Below  the  skin  and  super- 
ficial fascia  is  to  be  found  a  sac,  which  is  serous,  according  to  Broca,^ 
and  fatty  according  to  Alph.  Guerin,^  belonging  to  the  mons  veneris  as 

>  According  to  C.  A.  Martin  and  Leger  {Archives  generates  de  Medecine,18G2) 
the  secreting  apparatus  o£  the  external  genital  organs  in  woman  is  constituted 
solely  (with  the  exception  of  the  vulvo- vaginal  glands)  o£  sebaceous  racemose 
glands  and  some  sudoriparous  glands  which  are  only  found  on  the  external  or 
cutaneous  surface  of  the  labia.  The  muciparous  follicles  of  the  vestibule  of 
the  meatus  and  of  the  urethra  ai-e  only  mucous  crypts. 

'  Bulletin  de  la  Societe  anatomique,  Mars,  1851.  Morpain,  Mtudes  anato- 
miques  et  pathologiques  des  grandes  Icvres.  These  de  Paris,  1852,  No.  278. 
He  has  adopted  the  ideas  of  Broca. 

'  Maladies  des  organes  gSnitaux  externes  de  la  femme,  p.  243.     Paris,  1804. 


52 


INTEODUCTION 


much  as  to  the  lah'ia  majora,  extendiDg  from  the  external  inguinal  ring 
to  the  level  of  the  descending  ramus  of  the  pubis,  separated  above 


Pig.  48. 


Fig.  49. 


Fig.  50. 


Fig.  48, — Transverse  and  vertical  section  of   the  nymphse, — sebaceous  glands 

(after  Cniveilhier) . 
Fig.  49. — General  view  of  the  sebaceous  glands  of  the  vulva,  under  surface 

natural  size  (Martin  and  Leger). 
Fig.  50.— Sebaceous   glands    of  the  labia  majora  opening  into  a  hair-sac,  20 

diameters  (Martin  and  Leger). 


from  that  of  the  opposite  side  by  a  median  sac,  really  serous,  which 
prevents  friction  of  the  skin  on  the  pubis,  and  not  passing  beyond  the 
anterior  half  of  the  labium  majus. 

The  labia  majora  in  uniting  form  the  anterior  commissure,  below 
which  is  the  clitoris.  Behind  and  below  they  are  flattened  before 
uniting  to  form  a  posterior  commissure,  called  i\\efou7-cJieUe.  Between 
the  anterior  commissure,  and  especially  between  the  clitoris  and  the 
orifice  of  the  vagina,  is  the  vestibule.  Between  the  posterior  commis- 
sure and  orifice  of  the  vagina  is  the  fossa  navicularis.  The  nymphae, 
situated  within  the  labia  which  they  occasionally  exceed  in  their 
middle  portion,  are  forked  before  and  above,  i.  e.  below  the  anterior 
commissure,  so  as  to  form  a  kind  of  hood  or  foreskin  for  the  clitoris. 
They  enclose  a  great  number  of  sebaceous  glands  at  this  point.  They 
may  be  so  hypertrophied  as  to  exceed  the  labia  majora  to  a  certain 
extent  and  become  very  troublesome  under  some  circumstances,  e.  g. 
in  riding.     Both  surfaces  are  covered  with  mucous  membrane,  the 


ANATOMY,    THYSIOLOGY   AND    TEEATOLOGY  53 

internal  having  an  innumerable  quantity  of  little  glands,  generally 
arranged  in  three  or  four  concentric  rows. 

The  meatus  urinarius  is  situated  1  \  centimetres  behind  and  below 
the  clitoris ;  in  virgins,  as  a  rule^  it  is  a  mere  slit,  but  in  lascivious 
women  it  is  open,  owing  to  the  erectile  turgescence  all  round  the 
orifice.  Sometimes  it  is  half  closed  by  a  kind  of  inferior  median  ridge 
continuous  with  a  prominent  inferior  tubercle,  occasionally  double  (Fig. 
47),  the  termination  of  the  anterior  column  of  the  vagina  and  serving 
as  a  guide  in  catheterism.  The  meatus  is  generally  on  a  line  with  the 
vestibule  when  it  is  easily  discovered.  According  to  Alph.  Guerin, 
however,  in  women  who  have  had  precocious  intercourse  the  vulva  is 
pushed  backwards  and  the  meatus  concealed  under  the  symphysis  of 
the  pubis.  Sometimes  the  vaginal  orifice  is  gradually  dilated  without 
any  laceration  of  the  hymen  taking  place.  Generally,  however,  only 
traces  of  this  membrane  are  found  after  the  first  coitus.  These  vestiges 
are  known  by  the  name  of  carunculse  myrtiformes;  they  vary  in 
number,  size,  and  form,  according  to  the  individual  conditions  and 
the  amount  of  violence  used.  There  are  generally  four  or  five,  most 
frequently  one  inferior  and  always  two  lateral,  at  the  base  of  which  the 
orifices  of  Cowper's  glands  are  seen.  The  secreting  organs  of  the  vulva 
are  the  sebaceous  and  piliferous  follicles  and  the  muciparous  glands. 
The  sebaceous  and  piliferous  follicles  are  excessively  numerous,  and  are 
only  observed  on  the  mons,  on  the  labia  majora  and  minora,  and  in 
the  genito-crural  folds.  The  follicles  of  the  nymphse  are  simply  seba- 
ceous. The  muciparous  glands  are  grouped  within  the  nymphse,  nearer 
the  entrance  of  the  vagina.  Some,  already  described  by  several 
authors,  notably  by  Regnier  de  Graaf^  and  more  recently  by  Eobert,^ 
have  been  called  by  Huguier^  isolated  muciparous  follicles.  The 
others  form  a  true  gland,  designated  by  this  author  as  the  vaginal 
follicular  body  or  vulvo-vaginal  gland.  The  isolated  muciparous  folli- 
cles are  collected  especially  at  three  or  four  points  round  the  vaginal 
orifice ;  at  the  vestibule,  between  the  clitoris  and  the  urethra  (vestibular 
follicles) ;  circularly  round  the  meatus,  on  the  surface  of  the  central 
tubercle  which  limits  this  opening  below  {urethral  follicles) ;  at  some 
distance  from  the  meatus  and  on  its  sides  {urethro-lateral  follicles) ; 
lastly,  sometimes  on  the  lateral  portions  of  the  vaginal  entrance,  imme- 
diately below  the  hymen  or  upper  carunculm  myrtiformes  {lateral 
follicles  of  the  vaginal  entrance)  (JFig.  51). 

The  vulvo-vaginal  glands  described  by  Duverney,  Bartholin,  Garen- 
geot,  Morgagni,  Cowper,  and  lately  by  Tiedmann*  and  Huguier^  are 

*  Traite  des  parties  des  femmes  qui  servent  a  la  generation,  p.  120,  in 
VSistoire  anatomique  des  parties  yenitales  de  I'homme  et  de  lafemme.  Bale, 
1649. 

2  De  V inflammation  des  folUcules  muqueux  de  la  vulve.  Arch.  gen.  de  med., 
August,  1841. 

3  Memoire  sur  les  maladies  des  appareils  secreteurs  des  organes  genitaux 
externes  de  lafemme  {Memoires  de  I' Academic  de  medecine,  i.  xv,  p.  527,  et  seq.). 

*  Von  den  Duverney' sclien,  Bartlwlin  schen  oder  Cowper'schen  Driisen  des 
Weibes.     Heidelljerg,  1840.     See  also  Knox,  Lond.  Med.  Gaz.,  vol.  xxiii. 

»  Op.  cit.    Paris,  1841. 


54 


INTRODUCTION 


conglomerate  or  racemose  glands,  situated  right  and  left  of  the  entrance 
of  the  vagina,  small  before  puberty,  greatly  developed  in  voluptuous 


Fig.  51. 


Fig.  52. 


^t 


Fig.  51. — Muciparous  follicles  of  the  vulva,  a,  vestibular  follicles  ;  5,  lateral 
urethral  follicles ;  c,  central  urethral  follicles  ;  d,  lateral  follicles  of  the 
entrance  of  the  vagina;  e,  orifice  of  the  excretory  duct  of  the  vulvo- 
vaginal gland. 

Fig.  52. — Vulvo- vaginal  gland  and  its  excretory  duct  (after  Huguier).  a  a, 
section  of  the  labium  and  nympha  ;  h,  the  gland  ;  c,  its  excretory  duct ; 
e,  its  orifice  in  the  vulvo-carancular  sinus,  a  director  is  introduced ;  /, 
bulb  of  the  vagina ;  g,  ischio-pubic  ramus. 

/  women,  surrounded  immediately  by  a  fibro-vascular  envelope  in  relation 
with  the  transverse  artery  of  the  perineum,  placed  between  the  vagina 
and  its  bulb  (to  which  they  lie  close)  on  the  inner  side,  the  ischio- 
pubic  ramus,  which  is  1  centimetre  to  the  outside,  the  central  apo- 
neurosis of  the  perineum  situated  behind  and  above,  and  the  super- 
ficial aponeurosis  in  front  and  below.  They  are  bounded  on  all  sides 
by  resistant  layers,  so  that  pus  formed  internally  can  hardly  escape 
into  either  the  rectum  or  the  vagina  nor  run  together  as  in  abscesses 
of  the  labia.  The  excretory  duct,  2  centimetres  long,  opens  at  the 
union  of  the  lower  fourth  with  the  upper  three-fourths  of  the  vaginal 
orifice,  beyond  the  hymen  or  lateral  caruncula  myrtiformes,  at  the  base 
of  the  groove  which  separates  the  external  surface  of  these  carunculse 
from  the  internal  surface  of  the  nymphse,  where  it  may  often  be 
recognised  by  a  red  border.  Excitation  of  the  chtoris,  the  corpora 
cavernosa  and  the  bulb  of  the  vagina  greatly  increases  the  secretion 
of  the  vulvo-vaginal  glands. 

The  mucus  secreted  by  the  follicles  and  the  vulval  glands  is  acid, 
that  which  is  secreted  by  the  vestibular  and  peri-urethral  follicles  TiaT 


ANATOMY,  PHYSIOLOGY  AND  TERATOLOGY        55 

always  seemed  to  me  more  acid  than  that  which  is  secreted  by  the 
vulvo- vaginal  gland. 


Development — Comparison  op  the  Genital  Economy  in  the 

TWO  Sexes 

Bevelopmeni}-  takes  place  from  different  embryonic  points,  which  are 
more  or  less  independent  of  each  other  in  their  evolution.  The  external 
generative  organs  (the  vulva  and  its  dependencies)  are  developed  from 
the  external  layer  of  the  blastoderm ;  the  internal  generative  organs 
arise  from  the  middle  blastodermic  layer.  Hence  anomalies  may  be 
produced  in  one  of  these  formations  to  the  exclusion  of  the  other. 
There  is  even  a  point  of  central  formation,  which  is  neither  the  external 
layer  nor  the  intermediate  blastema,  but  the  septum  estabhshed  in  the 
primitive  cloaca  formed  by  the  rectal  cul-de-sac  and  the  bladder  which 
has  been  previously  derived  from  the  latter  under  the  form  of  the 
hollow  pedicle  of  the  allantois ;  the  vagina  is  developed  at  this  point, 
which  explains  a  relative  independence  between  the  anomalies  of  this 
portion  of  the  generative  system  and  those  of  other  parts.  In  short, 
each  of  these  portions,  especially  the  internal  one,  presents  in  its  turn 
several  centres  of  formation,  equally  endowed  with  a  relative  inde- 
pendence each  of  the  other,  and  capable  of  undergoing,  each  by  itself, 
arrests  in  development,  alterations  in  type  or  differences  of  direction, 
which  multiply  the  number  of  anomalies  and  which  may  carry  dis- 
similarities in  the  development  of  different  parts  of  the  same  economy 
as  far  as  that  difference  of  sexual  character  which  constitutes  herma- 
phrodism. 

A  few  words  will  suffice  to  explain  this.  At  the  beginning  the 
development  of  the  internal  generative  organs  takes  place  around  the 
Wolffian  bodies.^  These  bodies  atrophy  towards  the  end  of  the  second 
month,  leaving  probably,  as  traces  in  the  adult,  those  vestiges  of 
organs  in  connection  with  the  testicles  or  ovaries  known  by  the  names 
of  vas  aherrans  in  the  male  and  the  organ  of  Rosenmiiller  in  the 
female.  Whilst  the  Wolffian  bodies  atrophy,  new  organs  are  developed 
in  the  same  region.  These  are  the  kidneys,  the  ovaries  or  the  testicles, 
the  oviducts  or  the  spermatic  ducts,  &c. 

I.  Along  the  inner  border  of  the  Wolffian  body  there  is  a  fusiform 
enlargement  which,  increasing  gradually  in  size  and  diminishing  in 
length,  forms  the  first  rudiment  of  the  testicle  or  ovary.  Along  its 
external  border,  parallel  and  attached  to  its  excretory  duct,  but  quite 

•  See  Kiissmaul's  work,  Yon  dem  Mangel,  Verhummerung  und  Verdoppelung 
der  Gebdrmutter,  Wurtzburg,  1839 ;  as  well  as  the  work  of  M.  Lefort,  Des  vices 
de  conformation  de  I'uterus  et  du  varjin,  &c.,  Paris,  1863,  and  that  of  Guyon, 
Des  vices  de  conformation  de  I'urcthre  chez  I'homme,  Paris,  1863 ;  see  also 
Albers,  Die  weibliche  Cloakbildung  in  Monatssclirift  fiir  Geburtsh,  xmd  Frauen- 
Tirankheiten,  Berlin,  1860,  Bd.  xvi,  4*^  Heft ;  and  Koelliker,  Entwiclcelungsge- 
schichte  der  Menschen  und  der  hoheren  Thieve.     Leipsig,  1861. 

-  FoUin,  Becherches  sur  les  cori^s  de  Wolff.   Paris,  1850. 


56  INTRODUCTION 

independent  of  the  tubes,  there  is  a  second  organ,  at  first  a  simple 
solid  cord,  later  hollowed  into  a  canal,  known  by  the  name  of  Miiller's 
duct.     The  excretory  canal  of  the  Wolffian  body  and  Miiller's  duct 


Fig.  53.  Fig.  54. 

Tia.  53. — Wolffian  body  (aftei'  Coste).  c  v,  Wolffian  body  ;  s,  excretory  canal 
o£  Wolffian  body  ;  o,  future  ovary  or  testicle  ;  t,  future  oviduct  or  sperm- 
duct  called  Miiller's  duct ;  m,  future  uterus ;  the  figure  placed  alongside 
shows  tbe  glandular  structure  of  these  organs. 

Fig.  54. — Wolffian  body  and  internal  uro-genital  system  of  the  human 
embryo  after  the  fortieth  day  (after  Coste).  cv,  Wolffian  body  ;  o,  ovary 
or  testicle ;  s,  excretory  canal  of  Wolffian  body  ;  i,  sperm-duct  or  oviduct, 
Miiller's  duct ;  m,  future  uterus ;  c,  suprarenal  capsule  ;  r,  kidney ;  u, 
ureter ;  v,  bladder ;  gi,  large  intestine,  rectum. 

both  run  into  the  cloaca.  Now,  according  to  Rathke  and  Kobelt, 
whilst  the  sperm-duct  is  developed  from  the  excretory  canal  of  the 
Wolffian  body,  the  oviduct  proceeds  from  Miiller's  duct. 

In  the  first  period  of  intra-uterine  life  there  is  a  time  when  distinc- 
tion of  sex  is  impossible.  This  confusion  is  owing  to  similarity  of 
form,  which  soon  disappears  in  the  internal  as  well  as  in  the  external 
organs. 

If  Miiller's  duct  atrophies,  Wolff's  excretory  duct  forms  a  sperm- 
duct,  and  is  united,  by  means  of  tubes  afterwards  transformed  into  the 
epididymis,  with  the  germinative  organ  which  becomes  the  male 
generative  organ  or  testicle.  If  Miiller's  duct  is  developed  it  forms 
an  oviduct,  develops  at  its  extremity  a  Tallopian  tube,  and  remains 
distinct  from  the  germinative  organ,  i.  e.  from  the  ovary.  As  for  the 
germinative  organ,  it  is  united  to  the  sperm -duct  by  efferent  vessels 
(epididymis),  or  it  remains  isolated  from  Miiller's  duct,  with  the 
exception  of  the  interposition  of  a  certain  number  of  atrophied 
Wolffian  ducts  (organ  of  Eoseumiiller),  according  as  it  is  testicle  or 
ovary. 


ANATOMY,  PHYSIOLOGY   AND    TERATOLOGY 


57 


Thus,  the  Wolffian  body  never  entirely  disappears  either  in  the 
male  or  female;  its  elements  atrophy.  In  the  male  the  remains  of  its 
tubes,  besides  the  part  which  they  have  taken  in  the  formation  of  the 
epididymis,  frequently  become  small  epididymous  cysts,  and  form  pro- 
bably the  corpus  innominafum  of  Giraldes,^  the  rasa    aherrantia  of 


Fig.  55. — Figure  showing  the  organ  of  Rosen miiller.  Superior  right  angle  of 
the  uterus  (Ut)  and  portion  of  the  hroad  ligament  (LI)  with  oviduct  and 
ovary,  seen  from  behind  ;  Od,  isthmus  of  the  oviduct ;  Od',  largest  portion 
of  this  canal ;  J,  fimbriated  extremity  ;  Oa,  abdominal  orifice  of  Fallopian 
tube  ;  Fo,  fimbriae  ;  0,  ovary  turned  downwards  ;  Lo,  ovarian  ligament ; 
io,  infundibulo-ovarian  ligament ;  ip,  infundibulo-pelvic  ligament  divided 
at  its  pelvic  insertion ;  Po,  parovarium  or  organ  of  Eosenmiiller,  exposed 
to  view  by  the  ablation  of  a  portion  of  the  posterior  fold  of  the  broad 
ligament ;  *,  vascular  branch  which  follows  the  border  of  the  ovary. 

Haller.  In  the  female  the  Wolffian  body  becomes  the  organ  of 
Eosenmiiller,  its  central  tubes  end  in  the  hilum  of  the  ovary,  the 
outer  ones  disappear  or  atrophy  and  remain  the  analogues  of  the 
vasa  aherrantia ;  the  excretory  duct  of  the  Wolffian  body  disappears 
by  atrophy,  and  is  found  in  this  state,  in  the  cow  for  example,  on 
each  side  of  the  uterus  as  far  as  the  vagina,  where  it  terminates  under- 
the  name  of  Gsertner's  canal. 

Therefore,  according  to  the  form  of  development  affected  by  MUller's 
ducts  or  the  Wolffian  ducts,  an  oviduct  or  sperm-duct  is  produced,  and 
concurrently  with  it  an  ovary  or  testicle.  1.  One  of  these  forms  of 
development  may  appear  on  one  side,  whilst  another  is  produced  on 
the  opposite  side,  the  result  of  which  would  be  a  lateral  hermapbrodism. 
2.  The  two  forms  of  development  may  appear  incompletely  and  simul- 
taneously on  the  same  side  (but  much  less  frequently  so,  especially 

'  Becherches  anatomiques  sur  le  corps  innomine,  Journal  de  Brown-Sequard, 
t.  iv,  p.  1. 


58  INTRODUCTION 

as  regards  the  germinative  organ),  so  that  on  this  side  there  may 
be  produced  a  testicle  and  an  oviduct  or  an  ovary  and  a  sperm- 
duct,  and  even  a  testicle  and  an  ovary  superimposed,  a  phenomenon 
to  vehich  has  been  given  the  name  of  double  or  vertical  hermaphro- 
dism ;  only  we  must  remember  that  it  is  easy  to  be  led  into  error  in 
this  case  by  the  persistence  of  the  Wolffian  duct  or  of  Gsertner's 
canal.  3.  Lastly,  one  of  these  forms  of  development  may  take  place 
in  all  the  deep  organs,  which  will  be,  for  example,  all  male,  whilst 
the  opposite  development  is  effected  in  the  superficial  organs  which 
are  female,  the  result  of  which  would  be  transverse  hermaphrodism. 
As  regards  this  transverse  hermaphrodism,  the  independence  of  the 
development  of  the  external  and  internal  generative  organs,  which 
are  produced  in  two  fields  of  formation  quite  different  from  each 
other,  shows  that  it  may  occur  comparatively  frequently .^ 

Now,  in  order  to  understand  how  Miiller's  ducts  when  transformed 
into  oviducts,  are  developed  into  Fallopian  tubes  and  uterus,  and  how 
the  continuity  of  these  organs  is  estabHshed  with  the  vagina  and 
external  generative  system,  we  must  remember  that  development 
proceeds  simultaneously  on  the  intermediate  blastema  and  on  the 
internal  and  external  layers  of  the  blastoderm. 

On  the  internal  layer  this  development  takes  place  early.  The  allan- 
tois  produced  by  budding  from  the  anterior  surface  of  the  rectal  cul- 
de-sac  continues  attached  to  the  rectum  by  its  pedicle.  This  pedicle 
is  hollowed  out  into  a  canal  (urachus),  which  widens  at  its  point  of 
origin  in  the  rectum  into  a  reservoir  (the  bladder) ;  so  that  at  this 
period  the  bladder  and  rectum  form  a  true  cloaca  in  which  the 
genito-urinary  canals  terminate,  similar  to  that  on  the  exterior  which 
precedes  the  formation  of  the  anus  and  urogenital  orifice.  In  pro- 
portion as  the  uterus  is  formed  by  the  apposition  of  Miiller^s  ducts  the 
cloaca  is  divided,  allowing  the  formation  of  the  vagina  either  in  the 
blastema  interposed  by  this  division  between  the  bladder  and  the  rectum, 
as  is  supposed  by  Eathke  who  thinks  the  lower  part  of  the  uterus  is 
developed  in  the  same  way  or  by  the  prolongation  of  Miiller's  two 
ducts,  which  themselves  form  a  double  vagina  below  a  double  uterus. 

I  think  the  most  probable  hypothesis  to  be  that  which  limits  to 
the  uterine  cervix  the  formations  depending  on  Miiller's  ducts,  and 
which  supposes  the  vagina  to  be  developed  from  the  tissue  the  inter- 
position of  which  between  the  rectum  and  the  bladder  has  previously 
eflected  the  separation  of  these  two  reservoirs,  or  in  its  lateral  borders. 
I  will  give  my  reasons  presently. 

However  that  may  be,  we  can  in  any  case  say  with  certainty  that 
Miiller's  ducts,  during  the  development  of  their  lower  portion  whilst 
approaching  each  other  and  in  proportion  as  they  descend,  pass 
through  three  periods  characterised  by — 1,  complete  separation  and 
division;  2,  reunion  in  the  median  line;  3,  complete  fusion. 

Eunning  along  the  external  border  of  the  excretory  canal  of  the 
"Wolffian  body,  Miiller's  duct  changes  its  direction  lower  down  and 

^  GeofEroy  Saint-Hilaire,  Traite  de  teratologie.  Paris,  1836  ;  L.  Lefort,  op. 
cit.,  p.  174. 


ANATOMY,   PHYSIOLOGY    AND    TEBATOLOQY  59 

describes  a  half  circle  round  this  canal,  coining  in  front  and  to  the 
inner  side  of  it  to  meet  its  fellow  of  the  opposite  side  to  which  it 
becomes  attached  and  united  in  the  median  line. 

J.  Y.  Meckel  observed,  in  embryos   of  from  eight  to  nine  weeks, 
absolute  equality  in  calibre  and  the  absence  of  any  line  of  demarca- 


FiG.  56. — Development  of  the  internal  genito-urinarj  organs  in  a  human 
emhryo  older  than  the  preceding  (after  Coste).  c,  suprarenal  capsules ; 
r,  kidneys  ;  o,  ovaries  ;  u,  ureters  ;  t,  Fallopian  tubes ;  m,  uterus  ;  I  r,  round 
ligament ;  v,  bladder. 

tion  between  the  rudimentary  oviduct,  uterus,  and  vagina.  According 
to  Kiissmaul,  however,  at  about  three  months  the  womb  can  easily  be 
distinguished  from  the  vagina  by  a  somewhat  greater  thickness  and 
consistency ;  the  very  fine  oviducts  begin  to  become  flexuous,  and  are 
about  a  third  longer  than  the  corresponding  uterine  cornu.  The  sepa- 
ration between  the  oviduct  proper  and  the  uterine  cornu  is  marked  by 
the  insertion  of  a  fibro-muscular  cord,  afterwards  to  be  known  as  the 
round  ligament.  Meckel  justly  compares  this  organ  to  the  suspensory 
ligament  of  the  testicle  {guhernaculum  testis  of  Hunter).  Wrisberg 
designates  it  the  cremaster  of  the  womb,  and  Rathke  confirms  the 
analogy  by  the  study  of  its  development  in  the  embryo. 

Between  the  testicle  or  ovary  on  one  side  and  the  pubis  on  the 
other  extends  on  each  side  a  kind  of  ligament,  destined  to  become 
more  or  less  muscular,  having  connections  with  the  inguinal  canal, 
the  scrotum  or  labium.  The  presence  of  this  organ  determines,  in  the 
scrotum  or  labium,  the  peritoneal  prolongation  known  as  the  ijinica 
vaginalis  in  man,  canal  of  Nuck  in  woman,  the  obliteration  of 
which  takes  place  after  birth,  partially  in  the  one,  completely  in  the 
other.  Its  ulterior  changes  bear  a  relation  to  the  displacements  of  the 
testicle  and  ovary.  The  testicle,  descending  into  the  scrotum,  pushes 
before  it  the  gubernaculum  which  covers  it  and  which  is  transformed 
principally  into  the  cremaster ;  the  ovary,  descending  only  into  the 


60  INTEODUCTION 

pelvic  cavity,  preserves  its  relations  with  this  organ  which,  adhering 
to  the  oviduct  at  its  point  of  intersection  with  this  canal  and  there 
modifying  the  direction  or  the  number  of  its  contractile  fibres,  becomes 
the  uterine  ligament  of  the  ovary  in  its  upper  portion  and  the  round 
ligament  of  the  uterus  in  its  lower  portion.  The  portion  of  the  ovi- 
duct placed  above  it  forms  the  Fallopian  tube,  that  below  it  the  womb. 
The  two  uteri  are  recognisable  for  a  long  time  after  their  union  by  the 
projection  of  the  cornua  of  which  the  Fallopian  tubes  are  a  continua- 
tion. Gradually  the  fundus  rises  slightly  between  these  two  cornua 
but  for  a  long  time  without  the  organ  losing  the  traces  of  its  primi- 
tive duplicity.  The  womb  at  the  same  time  becomes  more  volumi- 
nous, more  cylindrical,  and  the  body  may  be  distinguished  by  the 
enlargement  of  the  upper  part.  This  portion,  however,  remains  in  a 
state  of  comparative  inferiority ;  for,  owing  to  the  length  of  the  neck,  it 
does  not  reach  the  third  of  the  total  length  of  the  organ  in  a  foetus  at 
term. 

To  sum  up  :  two  cords  at  first  solid  (Miiller's  ducts),  separated 
above  by  the  width  of  the  vertebral  column  and  of  the  Wolflian  body, 
are  united  below  back  to  back.  The  part  situated  above  the  point  of 
union  and  Hunter's  ligament  will  form  the  Fallopian  tube,  the  part 
below  will  constitute  the  uterus.  Each  of  these  cords  is  hollowed  into 
a  distinct  cavity,  then  the  partition  separating  the  two  disappears  from 
above  downwards,  and  the  uterine  canal,  at  first  double,  becomes  finally 
single. 

II.  Between  the  internal  generative  economy,  the  development  of 
which  we  know,  and  the  external  generative  economy,  the  formation 
of  which  we  shall  presently  study,  there  is  an  organ  of  transmission ^ 
the  vagina,  intermediate  in  function  as  in  position.  The  notions 
which  we  have  as  to  its  evolution  are  somewhat  hypothetical,  for  they 
are  deduced  partly  from  direct  observation  by  embryology,  partly  from 
indirect  observation  by  teratology.  We  have  seen  that,  within  the 
external  fold  of  the  blastoderm  while  still  imperforate,  there  is  a  true 
cloaca  or  cavity  common  to  several  hollow  organs.  This  cloaca  is 
the  termination  at  first  of  the  rectum  behind,  then  of  the  bladder  (dila- 
tation of  the  hollow  pedicle  of  the  allantois)  before,  and  finally  of  the 
excretory  canals  of  the  Wolffian  bodies,  of  Miiller^s  ducts  and  of  the 
ureters  laterally.  The  communication  between  the  rectum  and  bladder 
is  limited  above  by  a  band  or  elevation,  indistinct  at  first,  but  which, 
becoming  more  and  more  marked,  descends  from  above  downwards 
under  the  form  of  a  flattened  membrane,  and  gradually  separates  the 
intestinal  cavity  completely  from  the  reservoir  of  the  urine. 

It  is  in  the  central  blastema  forming  the  division  between  these 
two  reservoirs  that  the  vagina  is  soon  afterwards  developed  ;  it  has 
not  been  determined  whether  it  is  developed  from  above  downwards 
or  from  below  upwards,  but  it  is  certainly  produced  from  two  lateral 
canals,  communicating  above  with  the  uterine  necks  (the  probable  ter- 
mination of  Miiller's  ducts)  and  below  with  the  vulva  where  may  be 
found  a  double  hymeneal  orifice,  and  destined,  like  several  other  pairs  of 
organs,  to  unite  together,  the  absorption  of  the  partition  reducing  them 


ANATOMY,    PHYSIOLOGY    AND  TERATOLOGY  61 

to  a  single  canal  extending  from  the  uterine  orifice  (which  has  also 
become  single)  to  the  vulval  ring  developed  in  the  midst  of  the 
cutaneous  formations. 

Now,  if  the  membranous  band  destined  to  separate  the  rectum  from 
the  bladder  is  not  formed,  an  abnormal  communication^  (cloaca)  will 
persist  between  the  two  organs.  If  formed  incompletely  and  hollowed 
into  a  vagina,  a  double  communication  will  remain,  giving  rise  to  a 
double  congenital  fistula  (vagino- vesical  and  vagino-rectal).  If  the 
vesico-rectal  septum  is  formed  but  not  hollowed  out,  there  will  be  no 
vagina ;  if  hollowed  out  imperfectly,  there  will  be  a  partial  vagina ;  the 
superior  or  inferior  portion  may  be  in  turn  alone  developed,  or  two 
parts  may  exist  simultaneously,  the  one  superior,  the  other  inferior, 
between  which  there  may  be  at  a  variable  height,  a  transverse  partition, 
thick  or  thin,  imperforate  or  perforate.  Lastly,  if  the  primitive  double 
vagina  is  developed  normally  in  the  vesico-rectal  septum,  but  if 
the  development  is  arrested  there,  a  double  vagina  will  persist,  co- 
existing or  not  with  a  similar  arrest  of  development  in  the  uterus.  If 
the  two  canals  are  united  incompletely  the  malformation  will  be  limited 
to  a  partial  longitudinal  partition  between  the  right  and  left  portions 
of  the  vagina;  if  the  union  is  complete,  but  if  the  cavity  has  not 
enlarged  to  its  normal  extent,  there  will  be  a  congenital  narrowness. 

III.  The  external  generative  economy  ^q%^  not  begin  to  be  developed 
till  after  the  first  formations  of  the  internal  generative  organs,  particu- 
larly the  Wolffian  bodies.  In  an  embryo  of  thirty-five  days  an  accumu- 
lation of  blastema  may  be  seen  on  the  external  tegument  near  the 
caudal  extremity.  The  result  is  a  simple  oval,  central  eminence,  from 
which  afterwards  a  secondary  formation  of  buds  is  seen  to  arise, 
destined  to  form  a  series  of  appendages.  This  eminence  is  soon 
hollowed  out  in  the  centre  by  a  longitudinal  depression  which,  by 
corrosion  of  the  tegumentary  fold,  soon  becomes  an  external  linear 
orifice,  getting  deeper  and  deeper  and  terminating  (when  evolution 
progresses  regularly)  by  communicating  with  the  cloaca  of  which  we 
have  spoken  and  afterwards  with  the  vesical,  vaginal  and  rectal  cavities 
which  finally  become  distinct  and  independent.  Later  on  two  rounded 
eminences  are  developed  from  each  side  and  towards  the  upper  part 
of  this  slit,  destined  to  form  the  corpora  cavernosa  of  the  penis  in 
the  male,  the  clitoris  and  nymphse  in  the  female.  They  are  united 
at  first  by  their  upper  or  dorsal  surface,  leaving  a  lower  half-groove 
between  the  opposed  surfaces.  This  half-groove  persists  in  the  forma- 
tion of  the  female  economy;  in  that  of  the  male  it  is  closed  below 
by  a  kind  of  raphe,  which  converts  the  primitive  half-canal  into  a  com- 
plete one,  the  urethra.  The  malformation  known  as  hypospadias  results 
from  the  arrest  of  development  in  this  line  of  union. 

Below  these  eminences  two  others  are  developed,  which  in  the  male 
form  the  scrotum,  in  the  female  the  labia.  Lastly,  a  transverse  parti- 
tion is  developed  lower  down,  which  ultimately  becomes  the  perineum 
separating  the  anus  from  the  vulva. 

'  Puech  has  written  a  good  paper  on  the  uro-genital  cloaca.  Montpellier 
Medical,  Jan.  and  Feb.,  1868. 


62  mTRODUCTION 

It  is  by  the  disappearance  of  the  tissue  situated  between  the  rectal 
cul-de-sac,  the  vagina,  and  the  bladder  on  one  side,  and  the  external 
integument   on  the  other,  that  the  three  cavities — intestinal,  genital 


Fig.  57. — Development  o£  the  anus  and  external  genital  organs  in  a  human 
embryo  of  thirty-five  days  (after  Coste).  i,  intestine,  on  the  sides  of 
which  two  white  masses  are  seen  (Wolffian  bodies) ;  below  is  the  section  of 
the  urachiis  and  umbilical  arteries  and  veins ;  lower  still,  the  cutaneous 
fold  slightly  turned  back  over  the  ano-genital  orifice.  The  latter  consists 
in  a  simple  slit  in  the  centre  of  an  ovular  eminence,  m  i,  inferior  mem- 
brane ;  2>  caudal  prolongation. 

and  urinary — open  externally.  If  this  development  does  not  proceed 
regularly  and  completely  on  a  level  with  the  anal  depression,  the  rectal 
cul-de-sac  will  not  open,  and  there  will  be  an  imperforate  rectum. 
When  an  analogous  phenomenon  occurs  in  the  vaginal  portion,  there 
will  be  a  more  or  less  extensive  obliteration  of  that  part  of  the  vagina 
which  joins  the  vulval  ring  or  simple  imperforation  of  the  hymen. 

Comparison  of  the  generative  organs  in  the  two  sexes. — The  reader 
would  wish  me,  I  think,  to  follow  up  the  description  of  the  develop- 
ment of  the  uterus  and  its  appendages  by  some  observations  on  the 
independence  of  the  different  zones  in  which  the  genital  economy  is 
developed,  and  on  the  analogies  between  the  different  parts  of  this 
economy  in  the  male  and  female.  These  considerations  may  not  only 
throw  some  light  on  the  diagnosis  of  sexual  anomalies  in  general,  and 
help  in  determining  particular  cases,  but  they  may  also  lead  to  more 
frequent  and  immediate  applications  to  the  various  morbid  states  of  the 
genital  organs  than  one  would  at  first  be  apt  to  think. 

The  direct  observation  of  the  development  of  the  embryo  shows  that 
the  genital  economy  may  be  divided  into  three  zones,  which  must  be 
considered  as  three  distinct  seats  of  organic  evolution,  each  developed 
independently  of  the  others,  and  tending  to  produce  one  system 
destined  for  the  accomplishment  of  a  single  function.  Of  these  three 
zones  the  two  outer  are  principal,  the  middle  or  intermediate  one  is 
secondary.  The  former  are  the  internal  and  external  genital  organs, 
the  latter  is  the  means  of  union  between  the  two. 

The  middle  zone  is  simple :  the  vagina  is  developed  between  the 


ANATOMY,    PHYSIOLOGY   AND    TERATOLOGY 


63 


vulval  ring  belonging  to  the  external  zone  and  the  neck  of  the  uterus 
belonging  to  the  internal  zone,  almost  in  the  same  way  that  the  oeso- 
phagus is  developed  between  the  C2il-de-sac  of  the  stomach  pierced  by 
the  cardiac  orifice  and  the  cephalic  cul-de-sac  developed  into  the  buccal 


Fig.  58. 


Fig.  59. 


Fig.  58. — Development  of  the  anus  and  external  genital  oi'gans  in  a  human 
embryo  of  from  thirty- five  to  forty  days  (after  Coste).  o,  urachus  and 
pedicle  of  the  umbilical  vesicle,  the  umbilical  vessels  of  each  side ;  c, 
cutaneous  fold  of  the  umbilical  cord  wide  open ;  i,  intestine  ;  g,  centi"al 
projection  produced  by  the  development  of  the  genital  economy.  If  this 
projection  is  seen  in  front,  as  in  the  annexed  figure,  two  lateral  eminences 
will  be  observed  above,  the  origin  of  the  future  corpora  cavernosa ;  below, 
two  smaller  eminences,  the  origin  of  the  future  scrotum  or  labia.  On  the 
median  line  above,  a  slit  between  the  points  of  origin  of  the  corpus  caver- 
nosum ;  lower  down,  an  opening,  the  uro-genital  orifice  ;  lower  still,  a 
second  opening,  the  anus. 

Fig.  59. — Development  of  the  external  genital  organs  in  an  embryo  a^  little 
older  than  the  preceding,  the  sex  of  which,  however,  cannot  yet  be  dis- 
tinguished, p,  corpus  cavernosum  (penis  or  clitoris),  below  which  inins  a 
central  groove  terminating  in  the  uro-genital  orifice  ;  b,  scrotum  or  labia 
not  yet  united  in  the  median  line  ;  a,  anus. 

and  pharyngeal  cavity.  The  external  zone  is  complex,  but  this  com- 
plexity depends  only  on  its  structure,  and  not  on  the  difference  of  the 
seats  of  evolution,  its  whole  development  being  effected  at  one  and 
the  same  point  in  the  embryo.  The  internal  zone  is  more  complicated 
still,  for  the  character  of  this  complication  exists  in  the  multiplicity  of 
the  centres  of  formation,  the  ovaries  being  developed  along  the  internal 
border  of  the  Wolffian  bodies,  whilst  the  Fallopian  tubes  and  the 
uterine  cornua  are  formed  along  their  external  border,  the  Fallopian 
tubes  above,  the  cornua  below  the  point  where  the  oviduct,  considered 
as  a  whole,  crosses  Hunter's  ligament. 

These  various  centres  of  formation  are  precisely  the  points  at  which 
development  may  be  arrested  separately,  or  where  a  deviation  of  the 
plastic  act  may  be  manifested.  Therefore  the  anomaly  may  affect  the 
ovary,  Fallopian  tube  or  cornu  on  both  sides  or  on  one.  It  may 
extend  to  several  of  these  organs  at  once.  The  whole  internal  zone 
may  be  affected  or  the  intermediate  or  external  one.      The  two  former 


64  INTRODUCTION 

zones  may  even  be  affected  to  the  exclusion  of  the  third,  or  the  latter 
may  alone  be  affected ;  for  the  two  former  are  situated  in  the  blastema 
between  the  serous  and  mucous  folds,  and  the  third  in  the  serous  fold 
transformed  into  the  cutaneous  envelope.  Now,  my  teratological 
studies  have  led  me  to  consider  these  primordial  embryonic  folds  as 
seats  in  which  very  frequently  the  action  of  the  cause  which  brings 
about  an  arrest  of  development  is  exhausted;  between  these  points 
there  seem  to  be  limits  which  cannot  be  passed  by  any  known  terato- 
logical cause.^ 

As  for  the  analogies  which  embryology,  in  concert  with  relations, 
connections,  structure,  vascularisation,  innervation  and  functions, 
permits  us  to  establish  between  the  various  portions  of  the  genital 
economy,  male  and  female,^  I  shall  confine  myself  to  their  enume- 
ration. 

In  the  external  economy  the  analogy  is  striking  between — 


The  scrotum        .        .        .        , 
The  penis     .         .         .         .         . 
The  bulb  of  the  urethra 
The  glands  of  the  urethra    . 
Co\vper's  (bulbo-urethral)  glands , 


and  the  labia  majora, 
„      „    clitoris, 
„      ,,    bulb  of  the  vagina, 
„    those  of  the  vulva, 
„    Bartholin's  (bulbo- vulval). 


In  the  internal  economy  it  is  easily  demonstrated  between — 

The  testicles and  the  ovaries, 

The  cremasters „      „    round  ligaments, 

The  vasa  deferentia      .         .         .         •       „      „    Fallopian  tubes, 

The  lower  extremity  of  the  vasa  defer-  (  The  body  of  the  uterus,  with  the  glands 
entia  and  their  vesiculge  seminales   .  j      ""^    ^^\  ™^PT^'   membrane   and    its 

(.     muscular  richness. 

The  eiaculatory  ducts  opening  on  the'^      j    j-l  •        i     •  •    •, 

venimontanum,  separated  by  the  P^^  the  cervix  uteri,  conical,  and 
utriculus  and  surrounded  by  the  f  surrounded  by  its  glandular  agglo- 
prostate    ....■:.;      ^^^^'^n. 

Lastly,  the  intermediary  organ  is  represented  by — 

The  membranous  portion  of  the  xu'ethra  7      j  j.t-  •      • 

i't,  tyiot,  c  ^^"-  *"6  vagina  in  woman. 

This  last  analogy  may  seem  strange  without  a  little  reflection.  It 
is,  however,  easily  justified.  The  vagina,  in  fact,  is  developed  in  the 
blastema  between  the  rectum  and  bladder  immediately  above  the 
central  perineal  aponeurosis,  by  the  formation,  in  the  vesico-rectal  par- 
tition, of  a  canal  which  goes  to  meet  the  vulval  slit  on  the  one  side 

1  Memoire  sur  V absence  complete  du  vagin,  de  Vutenis,  des  trompes  et  des 
ovaires,  &c.,  with  remarks  on  the  absence  or  aiTest  of  development  of  the 
various  parts  of  the  genital  economy  of  the  female  and  general  considerations 
on  teratological  laws ;  in  the  Memoires  de  V Academic  des  sciences  et  lettres  de 
Montpellier,  t.  ii,  p.  321.    Montpellier,  1853. 

^  It  is  curious  and  very  interesting  to  pursue  these  researches  on  the  analogy 
between  the  various  parts  of  the  vascular  system,  the  nerves,  muscles,  apo- 
neuroses and  glands,  and  to  verify  the  wonderful  concordance  existing  between 
the  elements  which  correspond  in  the  male  and  female. 


ANATOMY,    PHYSIOLOGY  AND    TEEATOLOGY  65 

and  tlie  cervix  on  the  other.  It  is  identically  at  the  same  point  and 
in  the  same  way  that  the  membranous  portion  of  the  urethra  in  man 
is  formed,  in  front  of  the  urethral  crest  (junction  of  the  two  sperm- 
ducts),  behind  the  groove  of  the  penis  which  is  soon  converted  into  a 
canal  by  an  inferior  line  of  union  extending  to  the  bulb  where  is  also 
found  a  falciform  fold,  the  boundary  line  between  cutaneous  and  inter- 
mediary formations,  and  where,  when  catheterism  is  practised  on  the 
male,  the  catheter  is  frequently  arrested  before  penetrating  the  mem- 
branous portion. 

A  consequence  which  results  from  the  latter  analogy  seems,  at  first 
sight,  very  paradoxical,  namely,  that  in  man  there  is  no  proper  urethral 
canal  whilst  there  is  one  in  woman.  In  man,  the  canal  by  which  the 
urine  flows  from  the  bladder  is  nothing  but  the  analogue  of  the  vagino- 
vulval  canal  in  woman  developed  in  another  way  and  put  to  other 
uses.  In  man,  the  urinary  passages  properly  so  called  terminate  at  the 
neck  of  the  bladder.  The  canal  into  which  they  open  belongs,  by  its 
origin  and  destination,  to  the  genital  economy.  It  is  certainly,  and 
above  all,  the  propulsor  of  the  semen.  It  only  lends  itself  to  the 
excretion  of  the  urine  which  passes  through  it  from  one  end  to  the 
other,  traversing  successively  its  prostatic  (cervix),  membranous 
(vagina),  and  buibo-spongiose  (vestibule)  portions — a  new  proof  of  the 
differences  of  structure  or  of  destination  which  nature  can  imprint 
on  organs  fundamentally  identical.^ 

The  aim  of  such  research  after  analogies  leading  to  such  results  is 
chiefly  to  satisfy  the  mind  and  to  lead  it  to  the  philosophy  of  science ; 
it  may,  however,  also  lead  to  some  practical  applications.  The  physiolo- 
gist does  not  undertake  the  study  of  organic  analogies  because  he 
desires  to  force  a  resemblance  between  dissimilar  organs,  but  because  it 
is  interesting  to  observe  how  these  various  parts  are  gradually  formed 
and  differentiated  from  each  other,  although  their  embryonic  identity 
was  such  that  it  was  impossible  to  predict  their  future  condition ;  also, 
because  the  knowledge  of  these  analogies  leads  to  unexpected  anatomi- 
cal and  physiological  interpretations  stamped  with  the  most  living 
reality ;  and  lastly,  because  exact  and  useful  resemblances  may  be 
deduced  from  a  pathological  point  of  view  between  organs  proved  to 
be  anatomically  analogous. 


Anomalies 

The  majority  of  permanent  teratological  conditions  in  the  genital, 
as  in  all  the  other  organs  of  the  economy,  represent  transitory  embry- 

^  In  1849  I  pointed  out  all  these  analogies,  developing  them  in  a  paper 
entitled,  Des  diffa-ences  que  presente  I' organisation  dih  corps  hmnain  dans  les 
deux  sexes,  which  was  published  in  tlie  Annales  cliniques  de  Montpellier,  1855. 
My  colleague  and  friend,  Professor  liouget,  had  on  his  side  been  led  to  adopt 
similar  conclusions,  especially  with  reference  to  the  cervix  and  prostatic  portion 
of  the  urethra.  See  his  Beclierches  sur  le  type  des  organes  gmitaux  et  de  lews 
appareils  musculaires.    Paris,  1855. 

5 


66  '  INTRODUCTION 

onic  states.  Ifoerster/  Kiissmaul/  Leon  Lefort/  and  Klob*  have 
based  the  natural  classifications  which  they  have  made  of  these  mal- 
formations on  this  idea.  This  scientific  interest^  however,  is  not  the 
only  one  which  leads  us  to  say  a  few  words  on  the  anomalies  of  the 
genital  economy  of  woman.  The  cases  of  vaginismus,  impotence, 
dysmenorrhoea,  and  sterility,  which  are  simply  dependent  on  a  tera- 
tological  condition  of  the  genital  organs,  are  so  common  that  every 
day  in  practice  we  have  additional  proof  of  the  necessity  there  is  for 
the  physician  to  know  exactly  the  normal  disposition  of  the  sexual 
organs,  what  I  may  call  their  physiological  form,  so  as  to  be  able  to 
distinguish  it  without  difficulty  from  the  alterations  in  form,  size, 
situation  and  relations  which  suffice  to  prevent  the  accomplishment 
of  their  functions,  and  to  seize  easily  the  indications  that  must  be 
fulfilled  in  order  to  correct  these  anomalies  and  bring  them  back  to 
their  normal  conditions  or  conditions  resembling  their  normal  develop- 
ment. With  a  little  experience  we  can  often  guess  at  the  existence 
of  these  monstrosities  by  subjective  signs  and,  if  the  development 
of  the  sexual  economy  and  the  arrests  of  development  to  which 
it  is  exposed  are  present  to  the  mind,  we  can  easily  diagnose 
them  by  the  objective  signs  which  are  detected  by  methodical 
examination. 

In  giving  a  teratological  description  of  the  various  zones  of  the  genital 
economy  in  woman,  I  shall  omit  a  multitude  of  facts  which  are  only 
interesting  as  mechanical  causes  of  more  or  less  serious  derangements  in 
the  accomplishment  of  their  functions,  while  I  shall  place  in  the  hand  of 
the  physician  a  clue  which  will  enable  him  easily  to  find  his  way  through 
the  labyrinth  of  anomalies  which  suffice  to  produce  the  most  serious  func- 
tional disorders  and  become  the  starting-point  of  diseases  the  real  cause 
of  which  was  for  long,  and  is  even  now,  too  frequently  misunderstood. 

I.  General  Anomalies  of  the  Generative  System 
These  anomalies  may  be  characterised  by  an  absence  or  imperfection 
of  formation,  by  an  excess  of  development,  or  by  a  defect  or  deviation 
of  the  plastic  process.  The  first  kind  is  equivalent  to  absence  of  sex  or 
neutrality  in  the  individual,  the  second  to  real  hermaphrodism  by 
substitution  or  excess,  the  third  to  an  apparent  hermaphrodism. 

1.  Neutrality. — There  may  be  absence,  rudimentary  state,  imper- 
fection or  arrest  of  development  with  persistence  of  the  embryonic 
form  of  all  the  organs  constituting  the  three  zones  of  the  generative 
system,  or  of  all  the  organs  of  one  of  the  three  zones,  or  of  some,  or  of 
even  one  only  of  these  organs,  the  consequence  of  which  is  a  condition 
which  makes  it  impossible  for  the  individual  to  accomplish  functions 
devolving  on  organs  which  do  not  exist,  and  which  is  equivalent  to  the 

^  Manuel  d'anatmnie  patJiologique,  translated  by  Kaula,  p.  440.  Strasbourg, 
1853. 

2  Von  dem  Mangel,  VerTcilmmerung  u.  Verdoppelung  der  Geharmutter. 
Wiii-tzburg,  1859. 

^  Des  vices  de  conformation  de  I'uterus  et  du  vagin,  p.  23  and  following. 
Paris,  1863. 

*  Pathologische  Anatomie  der  weiblichen  Sexualorganen.   Vienna,  1864. 


ANATOMY,    PHYSIOLOGY    AND    TERATOLOGY  67 

absolute  privation  of  sex^  assimilating  the  woman  so  affected  to  tliose 
females  amongst  insects  (bees^  ants,  &c.)  designated  as  neiders,  owing 
to  the  absence,  rudimentary  condition  or  congenital  atrophy  of  their 
sexual  economy.  This  condition  may  produce  incapacity  for  repro- 
duction owing  to  the  absence  of  germination,  and  the  impossibility  of 
forming  a  germ  or  ovule,  or  it  may  lead  to  relative  impotence  owing 
to  the  difficulty  or  obstacles,  sometimes  quite  insurmountable,  which 
alterations  in  form  and  position  of  the  organs  produced  by  these 
arrests  of  development  put  in  the  way  of  coitus,  of  the  subsequent 
meeting  of  the  male  and  female  element,  and  of  fecundation;  or 
lastly,  there  may  be  germinative  impotence,  impossibility  of  fecunda- 
tion and  incapacity  for  gestation,  owing  to  the  absence  of  the  uterus 
itself.  I  have  seen  individuals  inscribed  in  the  civil  register  as  women, 
some  of  them  having  the  marks  of  a  feminine  organisation,  but  in 
whom  the  generative  functions,  by  an  arrest  of  development  affecting 
part  or  the  whole  of  the  sexual  economy,  were  so  annihilated  as  to 
assimilate  them  to  those  animals  known  as  neuters.  As  one  of  many 
interesting  cases  of  this  kind  which  I  have  seen  and  have  been  able  to 
examine,  there  was  one  on  which  I  had  to  give  an  opinion  based  on 
subjective  signs  alone  (the  subject  refusing  to  be  examined)  taken 
from  what  the  patient  herself  said  and  from  the  testimony  of  persons 
who  knew  her.  I  found  in  these  signs  proofs  which  enabled  the 
tribunals  to  declare  nullity  of  marriage  on  the  ground  of  error  as  to 
the  sex  of  one  of  the  parties.^ 

2.  True  Jiermaphrodism,  common  in  the  lower  animals  and  in  almost 
all  vegetables  (under  the  name  of  gynandry  or  androgyny),  was  till 
lately  believed  to  be  only  apparent  in  the  human  kind. 

Two  cases,  however,  are  now  recorded,  one  by  Eokitansky  and  another 
by  Heppner,  which  prove  to  a  certainty  that  the  simultaneous  presence 
of  organs  characteristic  of  both  sexes  may  be  found  in  the  same  in- 
dividual, not  only  the  one  on  one  side  the  other  on  the  other,  but  both 
simultaneously  on  the  same  side. 

There  is  no  longer  any  doubt  either  as  to  the  mode  in  which  the 
testicle  and  ovary,  sperm  duct  and  oviduct,  are  formed.  Eokitansky,- 
in  1869,  presented  to  the  Medical  Society  in  Vienna  the  results  of  the 
autopsy  of  a  person  named  Hoffmann,  in  whom  he  found  two  ovaries 
with  their  Fallopian  tubes,  a  rudimentary  uterus  and  one  testicle  with 
vas  deferens  containing  spermatozoa.  This  individual,  who  had  men- 
struated regularly,  had  an  imperforate  penis  and  a  bifid  scrotum ;  there 
was  absolute  sexual  indifference. 

Heppner,'^  of  St.  Petersburg,  has  published  the  interesting  results 

^  Courty,  Bemande  en  nullite  de  mariage,  fondee  sur  le  defaut  de  caracthres 
sexuels  feminins  ;  consultation  medico -leg  ale  et  considerants  du  jugenient. 
Montpeilier  medical,  t.  xxviii,  p.  473  ;  Montpellier,  1872  ;  and  Annates  de 
Gynecologic,  t.  ii,  pp.  325,  410.     Paris,  1874. 

^  Centralblatt  filr  die  inedicinisclie  Wissenschaften,  Berlin,  Union  medicale, 
3rd  series,  t.  vi,  p.  498.  Quoted  by  Maurice  Laugier,  Nouveau  dictionnaire  de 
medecine  et  de  chirurgie  pratique,  t.  xvii,  p.  505. 

3  Sur  rherniai)hrodisme  vrai  dans  I'esphce  hwnaine,  trad,  par  Douinic, 
Gazette  medicale  de  Paris,  1872,  p.  29. 


68 


INTEODUOTION 


of  the  autopsy  of  a  hermaphrodite  of  six  weeks^  preserved  in  alcohol 
for  several  years.  He  found  in  this  child,  together  with  a  complete 
internal  generative  apparatus  (ovaries  and  Fallopian  tubes,  uterus  and 
vagina  opening  into  the  urethra),  two  glands  which  microscopical 
examination  proved  most  clearly  to  be  two  testicles.  There  was  a  penis 
and  a  hypospadic  prostate,  but  neither  vesiculce  seminales  nor  vasa 
deferentia.  Thus  there  may  be  excess  of  formation,  not  in  the  external 
and  median  zones  which  are  never  double  and  in  which  a  male  de- 
velopment can  only  be  substituted  for  a  female,  or  vice  versa,  but  in 
the  inner  or  deep  zone,  where  the  male  and  female  germinative  organs 
may  exist  simultaneously,  not  only  the  one  to  the  right  and  the  other 
to  the  left,  but  both  on  the  same  side  and  even  both  on  both  sides, 
which  is  the  extreme  case  of  bi-sexual  hermaphrodism,  or  hermaphro- 
dism  by  excess.  In  most  cases,  in  place  of  finding  male  and  female 
organs  on  both  sides  or  on  one  side,  we  observe  male  organs  on  one 
side  and  female  organs  on  the  other,  or  male  organs  in  one  of  the 
zones,  or  in  a  part  of  one  of  the  zones,  and  female  organs  in  another. 


Fig.  60.— Apparent  female  hermaphrodism  owing  to  the  abnormal  development 
o£  the  clitoris,  obliteration  of  the  vagina  and  descent  of  the  ovary  into  the 
labium  (after  Anger).  The  first  fig.  represents  the  hermaphrodism  before 
the  operation  ;  the  second  after,  c,  clitoris  ;  sv,  sound  in  the  vulval 
orifice  ;  o,  ovary ;  v,  urethra  ;  Va,  vagina  formed  by  operation. 

or  in  a  part  of  another  zone.     "When  a  more  or  less  complete  male 
organism  on  the  one  side  co-exists  with  a  more  or  less  complete  female 


ANATOMY,    PHYSIOLOGY  AND    TERATOLOGY 


69 


organism  on  the  other,  this  anomaly  is  called  lateral  hermapTirodism. 
When  the  genital  economy  of  one  sex  is  developed  on  both  sides  in  one 
of  the  zones,  and  the  genital  economy  of  the  other  sex  in  another  zone, 
this  anomaly  is  called  transverse  hermaplirodism.  Lastly,  when  there 
is  co-existence  on  one  side  only  of  an  organ  of  one  sex  in  one  of  the 
zones  with  an  organ  of  the  other  sex  in  the  same  zone,  or  if  the  deep 
zone  belong  to  one  sex  and  the  central  or  superficial  zone  to  the  other 
(case  included  in  the  preceding),  it  is  called  vertical  or  double  Jierma- 
pkrodism. 

True  hermaphrodism,  therefore,  may  be  simple  or  double,  unilateral 
or  bilateral.  From  a  physiological  point  of  view  it  will  be  seen  that 
it  is  not  possible  for  a  hermaphrodite  to  effect  self-fecundation  nor  to 
assume  the  sexual  functions  of  both  sexes  alternately  with  another 
hermaphrodite,  as  do  the  lower  animals  when  similarly  organised ;  in 
fact,  this  apparent  wealth  is  in  reality  poverty.  When  there  is  an 
excess  of  organs  in  any  individual  this  excess  always  coincides  with  a 


Fig.  61. — Marie-Magdeleino  Lefort.  Section  oE  tlic  pelvis  sliowingtlie  sjenital 
organs,  s,  sound  passing  through  the  principal  orifice  below  the  clitoris  ; 
V,  vagina  ;  o,  ovary  ;  T,  Fallopian  tube  ;  u,  uterus  ;  Lr,  round  ligament ; 
C,  clitoris  ;  L,  labia. 

defect,  an  imperfection  or  an   absence  of  formation  in  these  organs. 
The  arrest  of  development  which  always  accompanies  these  singular 


70  INTRODUCTION 

anomalies  affects  not  only  the  additional  organs,  but  also  the  organs  of 
the  primitive  or  fundamental  sex — all  the  organs,  in  fact,  in  the  zone 
in  which  the  teratological  condition  is  manifested,  and  frequently 
those  in  the  other  zones  also. 

3.  Apparent  hermapJirodism. — In  most  cases  the  hermaphrodism  is 
apparent.  If  the  testicles  have  not  descended  from  the  abdominal  cavity, 
if  the  penis  has  remained  small,  the  two  halves  of  the  scrotum  sepa- 
rated, the  bulbo-spongiose  groove  open  and  communicating  directly 
with  the  membranous  portion,  and  if  the  urethra  terminates  in  hypo- 
spadias, the  cryptorchis,  the  species  of  vagina  of  the  intermediary  zone, 
and  the  arrest  of  development  in  the  external  zone  which  preserves  the 
appearance  of  a  vulva,  concur  in  giving  to  the  whole  of  this  sexual 
organism  a  feminine  aspect.  If,  on  the  contrary,  the  ovaries  have 
descended  by  the  inguinal  canal,  as  has  been  the  case,  if  the  bulbo- 
cavernous groove  be  closed,  the  labia  united,  the  clitoris  hypertrophied^ 
the  beard  developed  and  the  breasts  arrested  in  their  development,  the 
woman  in  many  respects  will  have  the  appearance  of  a  man  (Kgs.  60 
and  61) .  Lastly,  while  certain  organs  have  preserved  a  feminine  appear- 
ance, others  by  union  and  hypertrophy  may  have  assumed  a  masculine 
character,  so  that  the  most  unexpected  results  of  apparent  hermaphro- 
dism may  be  presented,  making  the  determination  of  sex  a  matter  of 
great  difficulty.  This  is  seen  in  the  history  of  a  certain  number  of  so- 
called  hermaphrodites  recorded  in  the  archives  of  science,  among  others 
in  that  of  Marie-Mag deleine  Lefort  (Fig.  61). 

The  reflections  suggested  by  the  knowledge  of  these  general  anoma- 
lies will  naturally  find  their  place  in  the  history  of  sterility,  which  is 
the  usual  consequence  of  these  teratological  conditions. 

II. — Anomalies  of  the  Ovaries 

Absence. — Of  all  the  anomalies  of  the  generative  organs  the  absence 
of  both  ovaries  is  not  only  that  which  occurs  most  rarely,  but  also  that 
which  is  most  frequently  accompanied  by  other  anomalies  of  other 
portions  of  the  generative  system. 

In  two  thirds  of  the  cases  in  which  absence  of  the  ovaries  has  been 
observed  the  vagina,  uterus  and  Fallopian  tubes  were  also  absent ;  in 
the  remaining  third  the  uterus  existed  but  was  imperfectly  developed, 
presenting  after  puberty  the  characteristics  of  fcetal  or  infantile  life.  A 
case  recorded  by  Depaul  is  the  only  one  which  leaves  any  doubts  as  to 
this. 

Notwithstanding  what  has  been  said  by  Scanzoni  this  anomaly 
is  not  marked  by  external  signs :  there  is  no  example  of  the  chin 
being  covered  by  a  beard  or  the  voice  being  rough  and  masculine. 
It  is  not  correct  either  to  say  that  the  breasts  are  rudimentary,  although 
Busch  and  Cripps  have  observed  one  case  of  arrested  development ;  they 
were  of  the  usual  size  in  seven  other  cases.  The  absence  of  symptoms 
indicating  ovulation,  with  the  existence  of  concomitant  anomalies  in  the 
uterus  and  vagina,  are  the  only  grounds  we  can  have  during  life  for 
diagnosing  or  rather  presuming  on  the  existence  of  this  anomaly.  At 
other  times  the  absence  occurs  only  on  one  side,  generally  on  the  left ; 


i.NATOMY,    THYSIOLOGY    AND    TEEATOLOGT 


71 


in  tins  case  the  uterus  has  usually,  if  not  always,  but  one  cornu  (Pig. 
62),  the  horn  corresponding  to  the  missing  ovary  being  also  absent 
or  reduced  to  a  cord.  In  twelve  cases  of  this  anomaly  the  ovarian 
function  was  exercised  normally,  with  regular  menstruation,  pregnan- 
cies and  children  of  both  sexes. 

Rudimentary  develojjment. — Two  features  characterise  this  anomaly, 
which  is  much  more  frequent  than  absence  of  the  ovaries  : — 1.  The 
small  size  of  the  organ.  2.  The  absence  of  Graafian  vesicles  at  ma- 
turity. From  a  physiological  as  well  as  from  an  anatomical  point  of 
view  two  forms  may  be  distinguished ;  in  the  first  the  organ  is  in 
outline  audits  structure  incomplete;  in  the  second  it  has  the  foetal 
organisation,  i.  e.  the  form,  size,  and  vesicles  proper  to  that  age. 
These  two  forms  occur  sometimes  with  a  normal  conformation  of  the 
uterus,  sometimes  with  an  anomaly  of  this  organ.     The  anomalies 


Fig.  62. — Left  unicorn  uterus,  absence  of  the  broad  ligament,  right  ovary  and 
Fallopian  tube,  c  rr,  cervix  uteri ;  o,  left  ovary ;  T,  left  Fallopian  tube, 
fimbriated  extremity.  The  right  border  of  the  rounded  uterus  (u)  is  covered 
with  peritoneum  (Klebs,  Handbuch  der  patJiologisclien  Anatomie.  Berlin, 
1873, 4«  Lieferang,  S.  761.) 

with  which  they  are  most  frequently  seen  to  coincide  are  complete 
absence  of  the  uterus,  apparent  absence  of  this  organ,  infantile  uterus 
and  hermaphrodism.  Eudimentary  ovaries,  though  rarely,  do  some- 
times coexist  with  a  uterus  normally  formed.  In  a  preparation  in  the 
Heidelberg  Museum,  described  by  Kiissmaul,  a  rudimentary  state  of 
the  ovaries  is  seen  in  a  woman  whose  uterus  is  5  centimetres  long  and 
3^  broad ;  the  vagina  is  replaced  by  a  fibrous  cord  3^  centimetres  in 
length  and  2  lines  in  width,  and  presenting  no  trace  of  a  canal,  except 


72  TNTEODUCTION 

in  the  upper  part.  Eoubaud,  in  an  analogous  case,  observed  that  all 
the  other  genital  organs  were  normal. 

At  other  times  only  one  of  these  organs  is  in  a  rudimentary  con- 
dition, either  when  the  corresponding  uterine  horn  is  atrophied 
(Granville,  Mayer  of  Eriburg,  Stolz,  Forster,  Rosenburger  and 
others),  or  when  it  is  normally  developed  (Morgagni,  Behling,  Lalle- 
mand,  Blot,  Scanzoni,  Forster).  The  rudimentary  condition  of  the 
two  ovaries  produces  the  same  consequences  as  the  absence  of  these 
organs ;  when  only  one  is  atrophied  menstruation  and  fecundation  take 
place  as  usual. 

Division. — Without  referring  to  varieties  of  form  and  size  which  do 
not  hinder  function,  we  shall  only  mention  the  depressions  and  notches 
which  these  organs  sometimes  present  in  their  borders,  in  adults  as 
well  as  in  infants.  Sometimes  single,  sometimes  multiple  (from  three 
to  six),  these  notches  are  generally  superficial.  At  other  times  the 
notch  is  much  deeper  and  accompanied  by  a  considerable  separation  of 
the  borders,  so  that  in  place  of  a  slit  the  ovary  is  really  divided,  into 
two  segments.  Klebs  and  Gintrac  have  seen  cases  where  the  two 
segments  of  the  ovary  were  united  by  a  kind  of  isthmus.  P.  Winckel, 
in  his  plates,  represents  an  ovary  divided  into  two  almost  equal  parts, 
on  one  of  which  an  accessory  ovary  is  seen  retained  by  a  peritoneal 
fold  and  having  a  Graafian  follicle;  a  similar  accessory  ovary,  also 
furnished  with  a  serous  pedicle  and  with  a  Graafian  vesicle,  is  repre- 
sented in  another  plate.  Beigel  has  met  with  this  anomaly  eight  times 
in  350  autopsies  and  Winckel  eighteen  times  in  500.  In  fact,  the 
ovary  may  be  composed  of  two  parts  entirely  separated,  as  was  proved 
by  the  preparation  presented  by  Grohe,  in  ]  863,  to  the  Congress  of 
Stettin  /  the  right  one  was  normal  and  well  developed,  whilst  on  the 
left  there  were  two  small  ovaries,  one  of  which  was  suspended  to 
the  uterus,  as  usual,  by  the  ligament  belonging  to  it,  the  other, 
situated  farther  off,  was  enclosed  in  a  peritoneal  fold.  The  woman  to 
whom  these  ovaries  had  belonged  had  had  three  children,  and  the 
three  ovaries  had  all  performed  their  function,  as  the  autopsy  showed. 

Ectopias. — There  are  two  kinds — lumbar  and  abdominal  or  in- 
guinal. The  lumbar  ectopias  described  by  Puech  (1855)^  are  arrests 
of  migration,  occurring  from  the  eighth  to  the  tenth  week  of  embryonic 
life,  i.  e.  when  these  organs,  as  well  as  the  Eallopian  tubes,  occupy  the 
lumbar  region  normally.  In  the  cases  quoted  the  ovary  and  the 
Tallopian  tube  were  not  in  any  way  attached  to  the  uterus ;  in  one 
the  latter  organ  was  absent;  in  the  other  only  the  right  horn  was 

1  Monatsschriftfm-  Geburt&kund,  &c.,  1864,  Bd.  xx,  p.  67.  Since  then,  in  1864, 
Klebs  observed  three  ovaries  in  one  woman.  De  Sinety  and  Olshausen  have 
published  analogous  cases,  but  the  most  remarkable  has  been  drawn  by  Winckel 
{Die  Pathologie  der  Weiblichen  Sexualorganen  in  LichtdntcJcabbildungen,  &c. 
Leipzig,  1872).  There  were  three  ovaries  and  three  ovarian  ligaments.  The 
third  ovary  and  its  ligament  were  on  the  anterior  surface  of  the  uterus,  touch- 
ing the  fundus  of  the  bladder,  without  any  peritoneal  inflammatory  adhesion. 
It  was  found  in  a  woman  of  seventy-seven  who,  although  married,  had  never 
had  a  child. 

'  Compte  rendu  de  I'Acad.  des  sciences,  22  octobre,  1855. 


ANATOMY,   PHYSIOLOGY  AND    TEEATOLOGY 


73 


wanting.  Inguinal  ectopias,  which  are  much  more  common,  may  be 
considered,  on  the  contrary,  as  excesses  of  migration,  having  for  prin- 
cipal agents  the  various  elements  which  concur  in  the  constitution  of 
the  round  ligament.  The  smooth  muscular  fibres  and  those  with 
transverse  striae  coming  from  the  abdominal  muscles  then  intervene 
and,  acting  in  the  manner  of  the  gnlernacidum  testis,  drag  the  Fal- 
lopian tube  and  ovary  after  the  round  ligament.  May  not  the  non- 
adherence  of  this  ligament  to  the  oviduct  where  it  joins  the  uterine 
horn,  favour  this  displacement  ?  The  canal  of  Nuck,  which  has  its 
maximum  of  development  from  the  fourth  to  the  sixth  month  of  intra- 
uterine life,  contains  these  organs  at  that  time,  and  the  descent  is 
completed  by  the  retraction  of  the  elements  of  the  round  ligament. 
The  ovaries  may  descend,  hke  the  testicles,  into  the  inguinal  canal  and 
cross  the  external  orifice,  even  reaching  the  labium.  The  persistence 
of  the  canal  of  Nuck,  the  narrowness  of  the  pelvis  and  the  elongated 
form  of  the  ovaries  favour  this  ectopia.  I  shall  not  add  more  now,  as 
I  shall  have  occasion  to  recur  to  the  subject  in  connection  with  hernia 
of  the  ovary. 

III.  Anomalies  of  the  Fallopian  Tithes 
They  sometimes  afi'ect  the  whole  organ,  sometimes  only  the  body  of 
the  oviduct  or  the  fimbriated  extremity. 


Fig.  63. — Right  unicorn  uterus  :  absence  of  broad  ligament,  of  ovaiy,  and  of 
ralloJ)ian  tube  on  left  side.  Matthews  Duncan,  Obstetrical  Journal,  vol.  i, 
p.  784. 


74  INTRODUCTION 

Absence. — The  complete  absence  of  the  Fallopian  tubes  is  very  rare, 
only  occurring  when  the  uterus  is  entirely  wanting.  Unilateral 
absence  has  been  observed  in  cases  of  unicorn  uterus,  conjointly  with 
that  of  the  ovary  (Fig.  63). 

Rudimentary  development. — The  Fallopian  tubes  may  be  represented 
by  traces  only,  or  by  more  or  less  developed  cords.  In  the  condi- 
tion of  traces  they  are  found  under  the  form  of  muscular  layers  occupy- 
ing the  upper  border  of  the  corresponding  peritoneal  fold.  One  would 
say  that  the  Fallopian  tube  itself  was  absent,  and  that  only  traces  of  its 
external  longitudinal  muscular  tunic  existed.  More  frequently  they 
are  observed  in  the  condition  of  solid  cords,  in  whole  or  in  part,  a 
disposition  which  can  only  be  connected  with  arrested  development, 
for  it  depends  on  imperforation  of  Miiller's  ducts  and  it  coexists  with 
other  anomalies  of  the  same  kind,  such  as  complete  absence  of  the 
uterus,  embryonic  uterus,  unicorn  uterus  with  rudimentary  horn  and, 
lastly,  complete  absence  of  the  cavity  of  a  uterus  apparently  normal. 
In  other  cases  the  tubal  canal  appears  well  developed  but  is  imper- 
forate, an  anomaly  which  coexists  with  the  absence  or  embryonic 
development  of  the  uterus,  or  with  the  atrophy  of  the  horn  in  cases  of 
unicorn  uterus.  In  other  cases  congenital  imperforation  only  affects 
the  fimbriated  end.  Baillie,  Eeynaud,  Guerard  and  Besnier  have  seen 
cases  of  this  kind.  Lastly,  there  may  be  a  striking  inequality  in  the 
length  of  the  two  Fallopian  tubes.  Puech  has  observed  such  a  case  in 
a  woman  married  for  ten  years  and  sterile ;  the  right  Fallopian  tube  was 
of  the  ordinary  length,  fourteen  centimetres,  whilst  the  left  was 
only  six. 

Vices  of  conformation. — The  Fallopian  tubes  sometimes  have  an 
apparent  shortness  depending  on  the  shortness  of  their  longitudinal 
muscular  tunic  and  on  the  more  numerous  and  deeper  folds  which  are 
the  consequences  of  it.  It  is  not  uncommon  to  find  contractions  at  some 
point  of  their  course,  and  at  other  times  dilatations,  either  primitive  or 
consecutive  to  the  existence  of  a  constriction  situated  below  and  which 
forms,  especially  when  obliterated  by  thick  mucus,  a  more  or  less  efficient 
obstacle  to  the  progress  of  fluids  from  the  Fallopian  tube  or  ovary 
towards  the  uterus.  But  it  is  principally  the  fimbriated  extremity 
which  is  subject  to  a  number  of  varieties ;  sometimes  the  widening  of 
the  tubal  canal  on  a  level  with  the  abdominal  extremity  is  slight  and 
its  opening  is  surrounded  with  very  short  fringes;  sometimes  the 
fimbriated  end  is  greatly  enlarged,  and  forms  below  a  sort  of  canal, 
which  is  in  close  communication  with  the  ovary  and  the  margins  of 
which  are  furnished  with  broad  fringes.  At  other  times  supernumerary 
fimbriae  are  to  be  seen,  as  described  by  Eichard  and  to  which  I  have 
already  referred  (p.  14),  to  the  number  of  from  one  to  three  on  the 
same  Fallopian  tube,  appearing  always  to  have  their  seat  on  the  upper 
wall  of  the  tube  and  presenting  a  single  opening.  Puech,  in  an 
autopsy,  saw  two  on  each  tube  placed  symmetrically. 

Ectopias. — They  may  be  lumbar  or  inguinal.  With  reference  to 
the  former  we  have  nothing  to  add  to  what  has  been  already  said  of 
lumbar  ectopias  of  the  ovary.     As  for  the  latter,  considering  the  close 


ANATOMY,  PHYSIOLOGY    AND    TERATOLOGY  75 

relations  of  the  Fallopian  tube  and  ovary  there  is  no  difficulty  in 
understanding  that  hernia  of  the  ovary  cannot  occur  without  the 
Pailopian  tube  accompanying  this  latter  organ.  As  for  hernia  of  the 
Fallopian  tube  occurring  alone,  a  few  cases  of  which  have  been  quoted 
by  Schiller,  Voigt,  Mayer,  Scholler  and  Berard,  they  are  produced  by 
a  mechanism  analogous  to  that  of  ovarian  ectopias. 

IV.  Anomalies  of  the   Uterus 

The  anomalies  of  the  uterus  are  numerous  and  varied,  but  at  the 
same  time  easy  of  interpretation. 

1.  Miiller's  ducts  may  be  undeveloped  or  atrophied,  in  which  case, 
if  the  ovaries  are  also  wanting,  there  will  be  complete  absence  of  the 
internal  genital  organs} 

2.  Want  of  development  or  atrophy  may  only  affect  the  portion  of 
the  two  tubes  destined  to  form  the  body  of  the  uterus ;  there  may  be  a 
vagina,  Fallopian  tubes  and  ovaries,  but  the  uterus  itself  may  be 
absent — uterus  dejiciens? 

3.  One  only  of  the  ducts  may  be  atrophied  or  incompletely  developed. 


Fio.  64. — Unlcoi'n  uterus  of  a  child,  seen  from  behind  (after  Pole),  a,  right 
unicorn  uterus  (left  half  of  uterus  is  not  developed)  ;  h,  right  Fallopian 
tube  ;  c,  left  Fallopian  tube  ;  d,  d,  ovaries ;  e,  bladder ;  /,  vagina,  in 
which  is  seen  the  uterine  orifice. 

the  other  continuing  its  evolution ;  the  uterus  may  be  only  half  an 
organ  and  there  may  be  only  one  Fallopian  tube,  the  other  half  being 
in  a  rudimentary  condition,  in  fact  one  horn  only  has  been  developed — 
vterus  unicornis  (Fig.  64). 

*  I  have  quoted  a  case  of  this  kind  :  Memoires  de  I'Academie  des  sciences  et 
lettres  de  Montpellier  (Section  of  Sciences),  t.  ii,  p.  321.  Montpellier,  1853. 
Comptes  rendus  de  I'Academie  des  sciences  de  Paris,  26  Sept.,  1853. 

^  Cases  are  on  record  known  in  which  absence  of  the  uterus  co-exists  with 
that  of  the  ovaries  and  Fallopian  tubes  (Busch,  Colombi,  Courty,  Klinkosch, 
Quain)  ;  others  with  absence  of  Fallopian  tubes  only  (Boyd,  Food,  Otto,  &c.)  ; 
others  with  the  presence  of  these  organs  (Burgrajve,  Gintrac,  Puech,  Serres, 
Ziehl,  &c.). 


76 


INTRODUCTION 


4.  Muller's  ducts  which  are  in  contact  with  each  other  at  their  inser- 
tion into  the  cloaca  may  remain  separated  in  the  whole  of  the  portion 
which  ought  to  form  the  uterus.  In  this  way  two  distinct  uteri  will  be 
formed,  each  of  which^  however,  will  only  represent  the  half  of  the 
normal  uterus.  The  rest  of  Miiller's  duct  is  hollowed  out  into  the 
form  of  a  tube  greatly  enlarged  at  its  free  extremity,  so  that  there  is  a 
double  uterus,  or  rather  two  uteri,  each  having  a  neck  and  body  and 
accompanied  by  a  Fallopian  tube  and  an  ovary — uterus  duplex,  diductus 
or  didelphis  (Fig.  65). 

5.  Miiller^s  ducts  may  be  brought  still  closer  together  without, 
however,  reaching  the  normal  type.  As  in  the  preceding  case,  the 
isolated  evolution  of  each  of  these  ducts  may  take  place,  but  their 
union,  being  incomplete  above,  will  produce  a  uterus  the  fundus  of 
which  will  be  hollowed  out  by  a  more  or  less  deep  anterior  groove 
dividing  the  upper  part  of  the  organ  only  into  two  portions  enlarged 
in  the  form  of  horns — uterus  bicornis  (Figs.  66,  67). 


Fig.  65. — Double  uterus  and  vagina  In  a  girl  of  nineteen  years  (after  Eisen- 

mann). 


ANATOMY,    PHYSIOLOGY    AND    TERATOLOGY 


77 


6.  The  union  of  the  tubo-uterine  canals  takes  place  at  the  normal 
point ;  the  fundus  of  the  uterus,  however,  in  place  of  continuing  its 


Fig.  66. — Double  bicorn  uterus,  and  double  vagina  in  a  girl  of  seventeen  (after 

Schrosder). 

development  by  a  median  enlargement  rising  to  the  level  of  the  ex- 
tremity of  the  horns,  remains  depressed,  as  in  the  fourth  month,  and 


Fig.  67. — Bicorn  uterus,  with  single  neck,  in  a  girl  (after  F.  C.  Ntegele). 


78 


INTRODUCTION 


the  fundus  of  the  uterus  is  incudiform  or  hiangular  (Pig.  68)  ;   or  it 
may  be  simply  indented  above  like  an  ace  of  hearts  and  may  keep 


Tia.  68. — Incudiform  or  biangular  uterus  in  a  girl  of  seventeen  (after  Oldham) ; 
this  an-est  of  development  recalls  the  form  of  the  uterus  at  the  fourth 
month. 

this  form  in  spite  of  the  absorption  of  the  partition  and  the  union  of 
the  two  cavities — uterus  cordiformis  (Fig.  69). 


Fig.  69. — Cordiform  uterus,  natural  size  (after  Kiissmaul).    a,  indented  fundus. 

7.  The  first  part  of  the  formative  evolution  (the  approximation  of 
Miiller's  ducts)  takes  place  regularly.  The  uterus  externally  is 
of  normal  form — litems  glohdans  (Figs.  70,  IV) ;  but  the  second 
part  of  the  work — the  fusion  of  the  two  uterine  canals  into  one 
by  the  disappearance  of  the  contiguous  walls  of   Miiller's  ducts — 


ANATOMY,    PHYSIOLOGY    AND   TERATOLOGY 


79 


is  not  accomplished ;  the  division  remains  intact  throughout  the 
length  of  the  organ,  both  body  and  neck — utenis  sejHus,  bilocularis^ 
dipariitis  {^igs.^T 0,71). 

8.  The  lower  portion  of  the  division  is  absorbed,  but  a  longer  or 
shorter  part  is  still  to  be  found  in  the  fundus ;  the  two  cavities  of  the 
uterine  horns,  though  separated  above,  communicate  below  to  a  more 
or  less  considerable  extent  j  the  neck  is  single — uterus  subseptus,  semi- 
partitus  (EgJIi). 


Fig.  70. — Double  uterus  and  vagina,  having  tlie  appearance  of  a  single  uterus 
and  a  single  vagina  with  partition,  in  a  woman  of  twenty-eight,  eight 
days  after  delivery  (after  Spaeth).  A  director  is  passed  through  the  cavity 
and  orifice  of  the  left  half  of  the  uterus  ;  gestation  took  place  in  the 
right  half. 

9.  The  uterus  is  normal  in  its  body,  but  there  is  atrophy  or  absence 
of  the  neck — uterus  with  rudimentary  neck  or  without  neck.  Or  the 
neck  may  be  normal  and  the  body  atrophied  or  absent,  a  case  of  which 
I  have  seen — uterus  without  body  or  without  fundus. 

10.  Lastly,  the  uterus  may  be  normal  in  form,  but  arrested  in  its 
nutrition  or  development  through  life,  remaining  an  embryonic  uterus, 
uterus  embryonalis  (Fig.  73)  or  a  foetal  uterus,  uterus  fcetalis] 
or  an  infantile  uterus,  utertis  infantilis;  or  in  the  condition  of  a 


INTEODUCTION 


uterus  before  the  establishment  of  the  menses,  uterus  jjiilescens p-  in 
factj  a  uterus  in  miniature,  the  majority  of  cases  incorreptly  designated 
as  2iterus  deficiens  being  properly  included  in  this  class ;  or  it  may  be 
solid,  the  cavity  not  hollowed  out,  and  Muller''s  ducts  being  also  solid  ; 


Fig.  71. — Double  uterus   (having  the  appearance  of  a  uterus  witli  paiiition) 
with,  single  vagina,  in  a  state  of  gestation  (after  Cruveilhier). 

at  other  times  it  is  only  imperforate  at  its  vaginal  orifice,  uterus  im- 
perforatus. Sometimes  the  vaginal  portion  of  the  neck  is  conical, 
cervix  acuminatus  (Fig.  74),  and  perforated  by  an  insufficient  orifice, 
either  in  the  centre  or  at  the  side.  "When  the  neck  is  conical  it  is  gene- 
rally too  long  and  may  require  to  be  partially  amputated.  Sometimes 
the  vaginal  portion  of  the  Deck  is  too  short,  or  it  may  be  completely 
absent,  cervix  dejic'iens  (I'ig.  74),  or  the  uterus  may  have  an  abnormal 
flexion,  vestige  of  the  foetal  state,  especially  anteflexion,  uterus  flexiis. 
In  Kiissmaul  there  are  woodcuts  of  lateral  flexions  produced  by 
foetal  deviations,  or  by  arrest  of  development  in  one  of  Miiller's 
ducts. 

Before  closing  this  chapter  on  teratology  I  must  give  a  particular 
description  of  the  anomahes  most  frequently  found  with  regard  to  the 
form  and  size  of  the  vaginal  portion  of  the  cervix.  Clinically,  it  is 
verv  important  to  be  able  to  distinguish  these  anomalies  by  sight  and 
touch,  to  be  able  to  i)ut  the  right  interpretation  upon  them,  to  know 

1  Puech,  Annales  de  Gynecologie,  t.  i,  p.  378. 


ANATOMY,   PHTSTOLOGT   AND   TERATOLOGY 


81 


the  diseases  which  they  can  produce,  and  to  be  sufficiently  familiar 
with  all  their  varieties  to  appreciate  a  distinction  between  those 
which  have  no  result  beyond  that  of  being  singular  and  those  which 


Fig.  72. — Rudimentary  bicom  uterus  in  a  woman  of  sixty  (after  Eokitanski). 
a,  vulva  ;  h,  a  band  of  cellular  tissue  mixed  with  muscular  fibres,  having 
the  form  of  a  uterus  (vaginS,) ;  c,  c,  muscular  cords  representing  the  uterine 
comua  (cervix),  and  terminating  in  enlargements,  d,  d,  of  the  size  of  a 
bean,  hollowed  out  into  a  cavity  capable  of  holding  a  lentil  and  covered 
with  mucous  membrane  (uterus)  ;  e,  e,  shrivelled-up  ovaries  ;  /, /,  oviducts  ; 
g,  g,  round  ligaments  ;  h,  h,  broad  ligaments. 

disturb  or  prevent  the  accomplishment  of  functions,  and  which  sooner 
or  later  may  become  the  starting  point  for  certain  diseases.  Between 
the  cervix  acnminatus  and  the  cervix  deficiens  just  referred  to  as 
extremes  of  condition,  there  are  many  varieties  of  anomalies  affecting 


Fig.  73. — Conical  neck  with 
narrow  orifice  (after  Sims). 


Fig.  74. — Absence  of  the  vaginal  poi-tion 
of  the  neck ;  the  uterus  rests  upon  the 
vagina  in  place  of  projecting  into  it. 


the  size  of  the  neck,  its  form  and  the  point  of  its  vaginal  insertion, 
or  the  form,  size,  situation  of  its  orifice,  &c.  The  number  of  anomalies 
1  have  observed  is  very  great,  but  I  shall  omit  all  those  which  do  not 

G 


82 


INTRODUCTION 


cause  any  sensible  alterations  in  the  functions  of  the  womb^  and  shall 
limit  myself  still  more  by  only  giving  examples  which  may  serve  as 
types  of  numerous  varieties  connected  together  by  a  more  or  less 
striking  resemblance.  With  reference  to  the  size,  the  neck  may  be 
deficient,  or  may  be  present  only  in  the  form  of  a  projection  approach- 
ing more  or  less  closely  to  the  normal  state,  or  lastly,  it  may  be  ex- 
cessive in  volume,  attaining,  even  in  nulliparae,  dimensions  which, 
though  seemingly  characteristic  of  acquired  hypertrophy,  are  sometimes 
really  caused  by  a  relative  arrest  of  development.  This  seems  para- 
doxical, but  the  fact  cannot  be  doubted  when  we  remember  the  large 
size  of  the  neck,  relatively,  in  the  foetus.  The  shape  varies  with  the 
size.  Sometimes  the  neck  is  depressed  at  the  extremity  of  the  vagina. 
Sometimes  it  projects  excessively  without  any  alteration  of  form,  or 
with  a  cylindrical  shape  very  slightly  different  from  the  normal.  Some- 
times it  is  completely  conical ;  at  other  times,  on  the  contrary,  it  is  quite 
the  reverse,  the  lips  being  turned  back  like  a  mushroom.  When  the 
lips,  instead  of  being  almost  equal  as  in  a  normal  condition,  are  un- 
equal, they  may  give  rise  to  alterations  of  form  still  further  removed 
from  the  primitive  type,  and  which  create  new  obstacles  to  the  accom- 
plishment of  the  functions.  If  the  orifice  is  directed  backwards,  the 
anterior  lip  projecting  beyond  the  posterior,  the  neck,  in  place  of 
having  the  shape  of  a  cone,  assumes  the  -aspect  of  a  snout,  as  may  be 
seen  in  Figure  75  drawn  from  nature  and  representing  the  appear- 
ance of  the  cervix  in  a  sterile  woman  married  for  eight  years.  The 
anterior  lip  may  project  still  more,  taking  the  form  of  a  beak,  or 
it  may  fall  over  the  posterior  lip,  covering  it  like  an  apron,  &c.  We 
shall  see  that  these  natural  tendencies  of  the  cervix  to  assume  the 
forms  of  a  cone,  mushroom,  snout,  &c.,  become  exaggerated  in  certain 
pathological  cases  giving  rise  to  hypertrophy,  when  the  same  forms 
become  monstrous  and  cause  so  much  trouble  and  pain  to  the  organ  as 
to  necessitate  an  operation.     This  exaggeration  only  serves  to  bring 


Fig.  75. — Cervix  in  form  of  snout,  the  anterior  lip  projecting  over  the  posterior 

(from  nature). 

into  relief  the  variety  of  abnormal  configurations  of  the  cervix.     The 
orifice  is  of  equal  importance.     In  place  of  having  the  aspect  of  a 


ANATOMY,    PHYSIOLOGY  AND    TERATOLOGY 


83 


fissure  bordered  by  two  lips,  auterior  and  posterior,  it  may  have  the 
form  of  a  more  or  less  narrow  circular  hole  in  the  middle  of  a  cylin- 
drical neck  slightly  projecting,  i.  e.  in  every  other  respect  like  the 
normal  condition.     It  is  possible  that  menstruation  may  occur  nor- 


FiG.  76. — Normal  or  linear  os  on 
a  depressed  neck. 


Fig.  77. — The  same  on  a  neck  of  normal 
shape  and  dimensions. 


Fig.  78. — The  same  on  a  voluminous 
neck,  with  lips  slightly  turned 
back  like  a  mushroom. 


Fig.  79. 


-The  same  on  a  voluminous 
conical  neck. 


mally,  and  even  that  conception  may  take  place.  Nevertheless,  such 
a  tendency  is  sufficiently  abnormal  to  cause  some  fear  lest  dysmenor- 
rhoea  may  set  in  after  marriage  if  not  before,  and  that  conception  will 
be  very  difficult,  and,  indeed,  highly  improbable.  As  a  rule,  a  uterine 
OS  having  the  form  of  a  circle  or  point  in  place  of  a  fissure  or  mouth 
(ostium  uterimim)  is  always  abnormal,  and  exposes  the  subject,  sooner 
or  later,  to  the  more  or  .less  troublesome  consequences  resulting  from  it. 
But  there  are  other  and  more  serious  anomalies.  The  one  most 
frequently  met  with  in  nullipara3,  and  one  which  is  the  cause  of 
innumerable  maladies,  is  that  of  a  narrow,  circular  os  coinciding  with 
an  anomaly  of  form,  principally  conicity  of  the  cervix,  or  with  an 
anomaly  in  the  position  of  the  orifice,  which  has  become  excentric  in 
one  direction  or  another.  In  place  of  being  in  the  centre  of  a  cervix 
of  normal  shape  the  utero-vaginal  orifice  may  be  situated  in  the  centre 
of  a  cervix  depressed  and  even  wanting.  This  case  is  rare  and  less 
important  than  the  others  in  its  consequences.  But  whether  the  neck 
projects  normally  or  is  depressed,  the  fact  of  the  pin-point  os  is 
serious ;  therefore  we  must  be  able  to  diagnose  it  and  not  be  misled 
by  the  appearance  of  a  fissure,  the  superficial  character  of  which  might 
be  overlooked  till  a  thorough  examination  shows  that  the  sound  only 
penetrates  into  the  uterine  cavity  by  the  pin  point  in  the  centre  of  the 


,84 


INTEODUOTION 


apparent  slit,     A  still  more  important  anomaly  is  that  of  a  pin-point 
OS  at  the  apex  of  a  conical  cervix ;  it  is  one  of  the  most  frequent  and 


Fig.  80.  —  Abnormal 
pin-point  os  on  a 
depressed  neck. 


Fig.  81. — The  same  on  a 
neck  of  normal  shape 
and  size. 


Fig.  82. — The  same  situ- 
ated laterally  on  a 
normal  neck. 


Fig.  83. — ^The  same  double 
or  bilateral,  at  the  two 
extremities  of  a  fissure, 
on  a  normal  neck. 


Fig.  84. — The  same  at 
the  apex  of  a  coni- 
cal neck. 


Fig.  85. — The  same 
situated  laterally 
on  a  very  coni- 
cal neck. 


most  troublesome,  since  the  narrowness  of  the  orifice,  whilst  producing 
dysmenorrhoea,  is  not  the  only  cause  of  sterility,  the  conical  form  of 
the  cervix  being  still  more  unfavorable  to  conception. 

In  all  cases  in  which  the  os  is  reduced  to  a  pin-point  dysmenorrhcea 
is  produced  sooner  or  later,  and  whether  the  neck  be  normal  or  conical 
— whether  the  orifice  be  in  the  centre  or  on  the  side — congestion 
occurs,  as  shown  in  the  six  preceding  figures  drawn  by  myself  from 
nature  or  taken  from  Barnes. 

The  narrowness  of  the  os  may  be  complicated  by  its  excentric  posi- 
tion, either  at  the  extremity  of  a  superficial  fissure  or  at  the  two 
extremities  of  a  similar  depression,  having  the  appearance  of  a  normal 
linear  orifice  bounded  by  marked  angles  or  commissures,  whilst  in 
reality  this  depression  is  the  vestige  of  that  period  of  development 
when  Miiller's  ducts  are  united,  but  when  the  intra-uterine  septum 
has  not  yet  been  absorbed  ;  therefore  in  making  a  careful  examination, 
in  the  first  case  the  inclination  of  the  sound  in  the  cervix,  in  the  other 
case  the  possibility  of  introducing  two  sounds  (one  into  each  orifice) 
which  may  or  may  not  touch  in  the  cavity  of  the  organ,  will  lead  us  to 
suspect  and  sometimes  even  to  diagnose  with  certainty  that  the 
case  in  question  is  one  of  unicorn  uterus,  or  of  two  uteri  incom- 
pletely united.     Quite  lately  I  was  able  to  diagnose  the  existence  of  a 


ANATOMY,    PHYSIOLOGY   AND    TERATOLOGY 


85 


right  unicorn  uterus :  the  pin-point  os  was  to  the  right,  the  cervix 
swollen ;  whilst  all  the  part  above  the  right  vaginal  cul-de-sac,  both 
before  and  behind,  was  tumefied,  probably  as  the  result  of  partial 
menstrual  retention  and  considerable  congestion  of  the  right  uterine 


Fig.  86. — Pin-point  orifice,  on  a 
normal  neck  congested  as  a 
consequence  of  dysmenor- 
rhcea  (acZ  «al). 


Fig.  87. — The  same  situated  laterally. 


Fig.  88. — The  same  situated  poste- 
riorly {ad  nat.  after  Barnes). 


Fig.  89. — The  same  situated  on  a  cylin- 
drical cervix. 


Fig.  90. — The  same  situated  on  a  cylindro- 
conical  cervix. 


Fig.  91. — The  same  on  a  conical 
cervix. 


horn,  the  presence  of  which  was  traceable  as  far  as  the  hypogastrium, 
on  a  level  with  the  brim,  towards  the  iliac  fossa  of  the  same  side  ; 
whilst  the  absence  of  any  solid  body  where  the  left  side  of  the  uterus 
should  be  led  to  the  supposition  of  the  absence,  or  at  least  the  imper- 
foration,  of  a  left  uterine  horn. 

Lastly,  very  frequently  the  narrow  os,  in  place  of  being  situated  at 
the  apex  of  the  conical  cervix,  is  at  some  distance  from  it,  very  seldom 
in  front,  more  frequently  to  the  right  or  left,  or  behind. 


86 


INTEODUCTION 


Another  anomaly  which  occurs  frequently  is  the  semilunar  form  of 
the  OS ;  whilst  this  does  not  cause  dysmenorrhoea,  it  makes  conception 
unlikely.  Generally  the  convexity  is  posterior,  occasionally  anterior. 
In  these  cases  there  is  an  arrest  of  development  with  persistence  of  the 


Fig.  92. — Semi-lunar  orifice  with 
anterior  concavity,  from  hyper- 
trophy of  the  anterior  lip. 


Fig.  93. — Semi-lunar  orifice  with 
posterior  concavity,  from  hy- 
pertrophy of  the  posterior  lip. 


inferior  part  of  the  central  column  of  the  arlor  vita,  a  vestige  of  the 
union  of  Miiller's  ducts  and  of  the  central  septum  which  primitively 
separates  the  two  uteri.  Tliis  obstacle  sometimes  occurs  in  the  canal 
or  at  the  os  internum,  where  it  is  not  visible.  In  other  women  it  is 
caused  by  an  inflammatory  hypertrophy  following  upon  previous 
deliveries,  or  consecutive  to  a  chronic  inflammation.  The  cause  varies 
but  the  effect  is  the  same. 


V.  Anomalies  of  the  Vagina 

Absence. — It  may  be  total  or  ])artial.     In  cases  of  total  absence  the 
vagina  is  replaced  by  cellular  or  fibrous  tissue,  and  in  both  cases  this 


Fig.  94. — Complete  ahsence  of  vagina,  which  is  replaced  hy  a  thin,  flattened, 
solid  cord  12  centimetres  long,  formed  of  cellular  tissue  and  longitudinal 
muscular  fibres  ;  retention  of  menses  for  seven  years,  puncture  by  rectum, 
purulent  peritonitis  causing  death  the  eighth  day.  V,  cord,  representing 
the  vagina ;  z,  round  ligament ;  L,  broad  ligament  ;  M,  section  of  the 
uterus  and  Fallopian  tubes  at  their  origin  ;  T,  Fallopian  tubes  dilated  to 
the  size  of  the  little  finger;  o,  ovaries  (after  Fiirst). 


ANATOMY,  PHYSIOLOGY  AND  TERATOLOGY        87 

defect  of  formation  may  coincide  with  absence  of  the  uterus  or  with  the 
existence  of  an  obliterated  or  embryonic  uterus^  or  with  the  existence  of 
a  normal  uterus  (Fig.  94).  The  partial  absence  may  be  more  or  less 
extensive ;  it  may  be  reduced  to  the  half  or  quarter  of  the  vagina,  and 
even  to  a  kind  of  membranous  septum,  there  being  an  insensible  tran- 
sition between  this  anomaly  and  a  simple  transverse  septum.  It  may 
coexist,  like  the  preceding,  with  absence  of  the  uterus  or  with  a  normal 
uterus. 

Arrest  of  development. — There  are  two  kinds  :  persistence  of  cloaca 
owing  to  defective  division  between  the  rectum  and  bladder,  and  per- 
sistence of  intra-vaginal  septa  from  defective  absorption  of  the  elements 
which  primitively  make  probably  a  solid  canal  of  the  vagina,  like  Miiller's 
ducts  from  which  the  Fallopian  tubes  and  uterus  are  formed. 

A.  Persistence  of  cloaca. — I  have  explained  (pp.  58,  60  and  61)  the 
mode  in  which  the  bladder,  rectum,  recto-vesical  septum  and  vagina 
are  developed  from  the  pedicle  of  the  allantois.  The  persistence  of 
the  cloaca  and  the  consequent  production  of  abnormal  communications 
between  the  vagina  and  the  bladder  or  rectum  are  to  be  attributed  to 
an  arrest  of  this  development.  The  cloaca  may  be  either  complete 
or  incomplete.  The  latter  may  be  uro-genital  (with  inferior  perfora- 
tion or  imperforation  of  the  vagina)  or  recto-genital  (with  vagiiial 
communication  or  imperforation,  or  rectal  communication  or  imper- 
foration) ;  examples  of  these  various  kinds  of  anomalies  have  been 
observed.  The  former  is  sometimes  complicated  by  abdominal 
eventration,  communication  between  the  vagina  and  the  anterior 
abdominal  wall,  or  extrophy  of  the  bladder;  at  other  times  it  exists 
without  any  other  anomaly  (Sue,  Velpeau,  Courty).  If  the  reader 
wishes  for  further  details  he  may  refer  to  Puech's  paper  already 
quoted,  as  I  shall  merely  mention  what  I  have  seen  or  what  has  come 
to  my  direct  knowledge.  I  have  seen  a  complete  uro-recto-vaginal 
cloaca  in  a  foetus  of  eight  months  preserved  in  alcohol ;  a  large  recto- 
vaginal cloaca  with  absence  of  the  entire  septum  in  a  newly-born  child ; 
a  superior  recto-vaginal  cloaca  with  absence  of  anus  and  lower  extremity 
of  rectum  in  a  little  girl  just  born;  an  inferior  recto-vaginal  cloaca 
with  imperforation  of  the  vulva  or  rather  of  the  lower  part  of  the 
vagina,  the  upper  part  of  which  communicated  with  the  rectum  and 
anus,  in  another  newly-born  child ;  a  communication  of  the  size  of  a 
five-shilling  piece  between  the  rectum  and  vagina  immediately  above 
the  hymen  and  external  sphincter  in  a  girl  of  nineteen,  and  a  similar 
one  with  imperforation  of  a  very  thick  hymen  in  a  girl  of  sixteen  who 
menstruated  by  the  anus ;  lastly,  an  opening  in  the  form  of  a  fissure 
three  centimetres  long  in  a  virgin  of  twenty-five,  in  whom  I  dis- 
covered at  the  same  time  a  double  vagina  and  double  uterus  which 
had  not  been  suspected,  and  on  which  I  operated  successfully  ;  it  was 
the  left  vagina  which  communicated  with  the  rectum.  Puech  has 
communicated  to  me  two  cases  of  congenital  absence  of  the  recto- 
vaginal septum  ;  in  the  first,  there  was  contraction  of  the  rectum  by  a 
membranous  diaphragm,  the  freces  being  excreted  by  the  vulva ;  in 
the  second,  there  was  at  the  same  time  absence  of  the  rectum,  and  the 


88  INTEODUOTION 

operation  (performed  to  give  exit  to  the  meconium)  was  followed  by 
death. 

B.  Division  of  the  vagina. — 1.  There  may  be  a  transverse  partition 
more  or  less  thick,  membranous,  complete,  incomplete  or  annular. 
This  anomaly  depends  on  an  arrest  of  absorption  at  some  point.  The 
persistence  of  the  entire  hymen  with  atresia  is  not  included  in  this 
anomaly,  or  rather  it  stands  on  the  borderland  between  anomalies  of 
the  vagina  and  vulva;  it  is  the  persistence  of  the  partition  existing 
primitively  between  the  genital  formations  of  the  external  layer  and 
those  of  the  intermediary  layer.  2.  A  longitudinal  partition  running 
from  before  backwards,  and  separating  a  right  from  a  left  vagina 
(double  vagina).  One  of  the  vaginse  may  be  imperforate  and  cause 
retention  of  the  menses  on  this  side.^  This  longitudinal  division 
may  be  complete  or  incomplete.  Both  anomalies  may  coexist  with 
uterus  bicornis,  uterus  septus  and  their  varieties,   or   with  a  simple 


Fig.  95. — 1,  pubic  symphysis ;  2,  bladder  ;  3,  uterus ;  4,  cul-de-sac  of  tbe 
posterior  wall  of  the  vagina  whicli  is  attached  to  the  fundus  of  the  uterus  ; 
5,  OS  uteri,  the  anterior  lip  of  which  adheres  to  the  anterior  wall  of  the 
vagina ;  6,  rectum  (after  Martini). 


uterus  (Maunoir).  Sometimes  only  a  vestige  of  this  anomaly  exists 
at  some  point  of  the  vagina,  more  frequently  at  one  of  the  extremities 
than  in  the  centre ;  I  have  referred  to  a  case  where  the  seat  of 
anomaly  was  at  the  hymeneal  extremity.  The  coexistence  of  the 
longitudinal  partition  of  the  vagina  with  a  simple  uterus  is  relatively 
rare  ;  whilst  more  than  100  cases  are  known  of  the  coexistence  of  this 
anomaly  with  anomalies  of  the  uterus,  there  are  not  fifteen  of  double 
vagina  coinciding  with  a  normal  uterus  (Puech).  3.  A  longitudinal 
septum  going  from  right  to  left,  separating  the  vagina  into  two  secon- 
dary cavities,  one  anterior,  the  other  posterior;  a  very  rare  anomaly, 
which  only   Bourjot  Saint-Hilaire,  Eugene  Eorget  and  Caradec  have 

'  Puech,  Des  atresies '  complexes  cles  voies  genitales  de  la  fcmme  ct  de 
I'liertiatometre  unilateral,  in  Annales  de  Gynecology.  Paris,  1875.  The 
author  has  collected  twenty-five  cases  of  this  anomaly. 


ANATOMY,   PHYSIOLOGY    AND    TEEATOLOGY  89 

observed  (each  one  case).  Is  it  not  possible  that  in  these  cases  there 
may  have  been  an  accidental  septum  ?  or  supposing  the  partition  to  have 
been  congenital,  may  not  its  direction,  so  different  from  the  preceding, 
be  due  to  a  deviation,  to  a  kind  of  torsion,  rather  than  to  an  absolute 
difference  of  direction  of  the  septum. 

Anomalies  of  size. — Amongst  other  anomalies  observed  in  the 
vagina,  the  most  remarkable  are  those  of  size.  With  respect  to  this, 
there  are  great  differences  in  women ;  and  in  some  these  differences 
exceed  the  normal  limits  and  constitute  teratological  states.  Some- 
times the  length  is  affected,  at  other  times  the  width.  As  to  the 
length  it  is  sometimes  excessive,  sometimes  defective.  The  shortness 
of  the  vagina  often  produces  a  marked  change  in  the  situation,  the 
relations  and  direction  of  the  uterus ;  this  shortness  does  not  depend 
only  on  want  of  material ;  it  often  results  from  vicious  insertions  of 
the  two  walls,  or  of  one  of  the  walls  of  the  vagina  into  the  cervix. 
These  insertions  are  sometimes  too  low  (an  arrangement  which  may 
simulate  absence  of  the  vaginal  portion  of  the  neck)  and  at  other 
times  too  high,  causing  abnormal  projection  of  the  cervix  into  the 
vaginal  cavity.  This  anomaly  is  especially  marked  when  only  one  of 
the  walls,  generally  the  posterior,  is  inserted  too  high ;  it  may  even  be 
inserted  into  the  body  of  the  womb  (T^ig.  95),  which  proves  that  the 
vagina  is  not  developed,  like  the  uterus,  from  Miiller's  ducts,  but  that 
it  is  an  intermediate  formation  between  these  canals  and  the  external 
genital  economy.  I  have  seen  a  great  many  examples  of  defect  in  the 
length  of  the  vagina  with  descent  of  the  cervix  as  a  consequence. 
The  uterus  is  deviated  in  one  or  the  other  direction  according  as  one  or 
the  other  vaginal  wall  is  the  shorter.  I  have  generally  found  the 
anterior  one  the  shorter.  As  to  amplitude,  sometimes  there  is  excess, 
which  disposes  to  prolapsus ;  sometimes,  on  the  contrary,  the  vagina  is 
too  narrow,  as  proved  by  the  numerous  cases  described  by  Antoine, 
de  la  Toison,  Beuevoli,  Plenck,  Scanzoni,  &c.  This  deformity  may  be 
confined  to  a  small  part  of  the  vagina,  to  a  kind  of  diaphragm  with 
central  orifice.  Sometimes  it  extends  further,  giving  to  the  vagina 
the  appearance  of  a  funnel,  broad  below  and  narrow  above.  At 
other  times  it  extends  to  several  centimetres,  but  may  yield  to 
dilatation  with  prepared  sponge,  sometimes,  in  fact,  it  reduces  the 
vagina  throughout  its  whole  length  to  a  narrow  canal  like  the  urethra. 
It  may  cause  serious  obstacles  to  the  accomplishment  of  the  sexual 
functions,  especially  to  delivery,  and  may  necessitate  the  intervention 
of  surgery. 

YI.  Anomalies  of  the  Vidva 

Absence. — The  complete  absence  of  the  vulva  has  frequently  been 
observed  in  monstrosities,  especially  in  acephalse,  symmeles,  &c.  (Louis, 
J.  L.  Petit,  &c.). 

Arrest  of  development  may  consist  in  a  rudimentary  state  of  all  the 
elements  of  the  vulva,  or  in  the  partial  absence  of  one  or  other  of  tiiese 
elements,  cither  of  the  labia,  nymphse,  or  clitoris ;  or  in  a  persistent 
bifidity  of  this  erectile  organ,  the  corpora  cavernosa  of  which  are  not 


90 


INTEODUOTION 


entirely  united  (Arnaud,  Morpain)  ;  or,  lastly,  in  an  imperforation,  a 
complete  atresia  of  the  hymen,  which  supposes  an  arrest  in  the  work 
of  absorption  of  this  membrane,  the  result  of  which  is  to  make  the 
external  genital  zone  communicate  with  the  median  zone. 

Excess  of  development  may  take  place  in  the  labia  or  nymphse, 
which  may  be  double  or  triple  in  number,  or  may  acquire  colossal 
dimensions  (apron  of  the  Hottentots) ;  or  the  hymen  may  be  com- 
pletely absent,  which  can  only  occur  from  excess  of  absorption ;  or  the 
clitoris  may  assume  the  size  of  a  small  penis ;  or  there  may  be  union 
of  the  nymphse  or  of  the  two  margins  of  the  vulval  groove,  and  even 
of  the  labia,  so  as  to  present  the  appearance  of  a  scrotum,  in  front  of 
which  there  would  be  a  hypospadias  surmounted  by  a  small  penis, 
giving  the  most  complete  appearance  of  female  hermaphrodism.  The 
resemblance  becomes  still  more  striking  when  the  ovaries,  or  one  of 
them,  form  an  inguinal  hernia  and  descend  into  the  sacs  of  the  labia. 

The  hymen,  which  is  between  the  external  and  median  genital  zones, 
presents  anomalies  which  are  also  very  interesting  to  study,  owing  to  the 
connection  which  often  exists  between  them  and  anomalies  or  altera- 
tions of  the  internal  organs.  They  are  represented  in  the  following 
woodcuts,  which  are  taken  from  the  thesis  of  Roze  and  from  drawings 
which  I  myself  have  made  from  nature. 

The  first  (Fig.  97)  is  imperforation  of  the  hymen  (Roze).     I  have 


Fia.  96.- 


-Hymen  of  normal  form 
in  the  virgin. 


Fig.  97. — Imperforate  hymen. 


seen  several  cases,  and  have  always  operated  by  incision  without  any 
accident.  The  thickness  of  the  imperforate  hymen  is  very  variable; 
sometimes  it  is  very  thick  and  formed  not  only  of  skin  but  of  a  cellular 
layer  lining  it,  whilst  at  other  times  it  is  constituted  by  a  simple 
epidermic  layer  (Courty)  which  tears  at  the  slightest  contact 
without  a  drop  of  blood,  as  I  have  lately  seen  iji  a  child  of  six  months. 


ANATOMY,    PHYSIOLOGY    AND    TEEATOLOGY 


91 


The  second  (Fig.  98)  is  a  hymen  divided  by  a  simple  fissure 
(Roze). 

The  third  (Fig.  99)  is  a  larger  fissure  giving  rise  to  a  bilabial 
hymen  with  irregular  borders  (Ledru). 


Fig.  98. — Hymen  witli  fissure.  Fig.  99. — Bilabial  hymen  witli  irregular 

margins. 

In  the  fourth  (Fig.  100)  absorption  of  the  tissue  and  perforation  of 
the  hymen  has  taken  place  at  several  points  simultaneously,  giving 
it  an  appearance  like  the  rose  of  a  vratering  can  (Roze). 


Fig.  1<)(). — Hymen  perforated  like  rose  Fig.  101. — Puckered  hymen  with 


of  a  \vatcrin<r-fiin. 


central  orifice. 


92 


INTRODUCTION 


The  fifth  (Pig.  101)  is  a  puckered  hymen  with  a  central  orifice 
(Roze) . 

The  sixth  and  seventh  (Figs.  102  and  103)  are  hymens  with  a 
circular,  or  rather  polygonal,  central  orificcj  with  from  four  to  six  lips, 
which  are  a  kind  of  carunculae  (Roze). 


Fig.  102. — Hymen  with  polygonal 
orifice  and  four  carunculge. 


Fig.  103. — Hymen  with  polygonal 
orifice  and  sls  caruncnlse. 


The  eighth  (Fig.  104)  is  a  hymen  with  a  circular  opening,  but 
with  serrated  edges  (Ledru).  It  is  singular  that  in  these  cases  the 
circumference  of  the  meatus  was  also  serrated. 


Fig.  104. — Hymen  with  serrated  borders.  Fig.  105. — Horse-shoe  hymen. 


ANATOMY,   PHYSIOLOGY   AND    TEEATOLOGY 


93 


The  ninth  (Kg,  105)  is  a  semilunar  hymen,  but  the  upper  angles  are 
broader  and  prolonged  towards  the  upper  border  of  the  vulval  ring, 
which  has  led  to  its  being  called  a  horse-shoe  hymen  (Roze).  I  have 
recently  seen  one  of  these  thick,  resistant  hymens,  very  broad  and 
allowing  of  considerable  dilatation,  in  a  virgin  of  thirty  affected  with  a 
myoma  of  the  body  of  the  uterus  with  marked  descent  of  the  anterior 
vaginal  wall  (Coui'ty). 

The  tenth  (Fig.  106)  is  a  hymen  with  a  circular  orifice  situated  to 
the  left  side  (Roze),  probably  belonging  to  a  double  vagina  imperforate 
on  the  right  side. 

The  eleventh  (Fig.  107)  is  a  hymen  with  two  orifices  or  biperf orate 


Fig.  106. — Hymen  perforated  at  left  Fig.  107. — Biperforate  hymen, 

side. 

(Roze),  tlie  orifices  being  probably  vestiges  of  the  primitive  duplicity 
which  extends  from  the  two  uterine  horns  to  the  two  hymeneal  orifices, 
passing  through  the  double  vagina  (Courty). 

The  twelfth  (Fig.  108)  is  a  hymen  with  two  well-marked  openings, 
almost  equal,  observed  in  a  young  girl,  who  menstruated  regularly  and 
without  pain,  in  whom  the  inter -hymeneal  septum  extended  from  1  to 
2  centimetres  into  the  vagina,  being  a  vestige  of  the  inter-vaginal 
septum  which  had  not  entirely  disappeared  (Courty). 

The  thirteenth  (Fig.  lOD)  is  a  biperforate  hymen,  one  of  the 
orifices  being  smaller  than  the  other,  without  any  trace  of  median 
vaginal  septum,  observed  by  myself  in  an  old  maid,  and  at  another 
time  in  a  married  woman  of  twenty-six  aff"ected  with  membranous 
dysmenorrhcca  without  any  symptom  of  teratological  condition  of  the 
uterus.  The  septum  was  applied  against  the  right  vaginal  wall,  and 
had  a  direction  and  position  which  made  it  certain  that  the  left  orifice 
only  had  been  used  in  copulation.  She  was  not  aware  of  the  anomaly 
till  I  discovered  it  (Courty). 


94 


INTRODUCTION 


Fig.  108. — Biperforate   hymen  with     Fig.    109. — Biperforate  hymen  with 
equal  orifices,  with  prolongation  unequal  orifices, 

of  the  inter-hymeneal  septum 
to  1  or  2  centimetres  into  the 
vagina. 

The  fourteenth  (Pig.  110)  is  the  hymen  with  double  semilunar 
orifice,  equal  on  both  sides,  forming  the  continuation  of  a  double  vagina 
represented  in  Pig.  65  (Eisenmann). 


Fig.  110. — Biperforate  hymen,  forming  the  continuation  of  a  double  vagina 

and  double  uterus. 


PAET    I 

GENERAL  SURVEY  OF  UTERINE  DISEASES 
CHAPTER    I 

DIAGNOSIS  OF  TTTEEINE  DISEASES  IN  GENERAL — PEESTJMPTIVE  SIGNS  PUENISHED 
BY  THE  SYMPTOMATOLOGY  OP  UTEEINE  DISEASES — CEETAIN  SIGNS  PUENISHED 
BY  DIEECT  EXPLOEATION. 

It  is  constantly  said  that  diseases  of  the  uterus  are  far  more  common 
now  than  formerly ;  but  this  is  an  error  which  can  be  easily  accounted 
for.  Our  forefathers  recognised  these  diseases  less  frequently  because 
they  knew  less  about  them,  and  because  they  often  ascribed  to  other 
causes  the  serious  and  even  fatal  results  produced  by  them.  Sometimes 
they  successfully  treated  the  morbid  symptoms,  and  so  got  rid  of  the 
disease  without  being  aware  of  its  existence ;  and,  indeed,  we  know  that 
a  certain  class  of  these  affections  will  really  yield  to  simple  hygienic 
measures. 

It  is,  then,  of  the  first  importance,  before  entering  on  the  study  of 
individual  diseases,  to  gain  a  general  view  of  the  symptoms  which  all 
uterine  maladies  possess  in  common,  and  which  may  reveal  or  conceal 
the  true  state  of  the  case,  according  to  the  attention  and  skill  of  the 
observer.  We  must  point  out  that  uterine  diseases  have  many  of  these 
common  symptoms,  which  indeed  were  almost  the  only  ones  formerly 
known ;  and  in  certain  cases  it  is  quite  possible  to  apply  a  similar,  if 
not  identical,  treatment  to  them,  with  reasonable  chance  of  success. 
We  must  also  indicate  the  measures  by  which  morbid  conditions  de- 
pending on  uterine  diseases,  as  well  as  the  diseases  themselves,  can  be 
ameliorated  or  cured. 

This  introduction  will  help  us  to  understand  how  our  forefathers 
failed  to  recognise  these  diseases,  and  how  they  sometimes  cured  them 
without  having  suspected  their  existence ;  and  it  will  also  give  us  the 
key  to  the  errors  into  which  several  gynecologists  of  the  first  half  of  this 
century  fell,  in  supposing  a  simple  morbid  state  to  be  the  prime  factor 
in  all  uterine  pathology.  They  arrived  at  too  hasty  conclusions  from 
the  new  means  of  investigation  put  into  their  hands  by  the  inventive 
spirit  of  the  age,  and  did  not  see  that  if  the  ancients  erred  in  ignoring 
the  great  mass  of  uterine  diseases,  they  themselves  were  almost  equally 
wrong  in  simplifying  its  pathology  to  the  extent  of  embracing  all  in  one 
type  of  malady. 

Lisfranc  and  his  disciples  found  the  explanation  of  all  uterine  diseases 
in  congestion,  Yalleix  in  displacements.  Those  who  followed  Blatin 
and  Tyler  Smith  thought  leucorrhcDca  the  great  evil,  while  Recamier 


96  GENERAL    SURVEY   OF  UTERINE    DISEASES 

and  his  school  talked  of  ulcerations  and  granulations.  The  more 
modern  teachers,  like  Bennet^  Nonat  and  even  Aran,  although  recog- 
nising distinctions  in  the  morbid  states,  were  inclined  to  trace  them  all 
to  the  common  source  of  inflammation. 

Prom  this  exclusive  pathology  came  equally  exclusive  therapeutics. 
Those  who  saw  congestion  everywhere  kept  their  patients  in  bed ;  those 
who  only  discovered  displacements  applied  mechanical  treatment  only. 
Some  directed  all  their  attention  to  curing  leucorrhoea  as  the  cause  of 
any  ailment,  and  thus  concentrated  their  efforts  on  the  destruction  of 
ulcerations  by  caustics  or  the  actual  cautery.  Others,  again,  devoted 
themselves  resolutely  to  subduing  inflammation  by  bleeding,  baths  and 
emollients. 

Thus  it  appears  that  uterine  medicine  has  passed  through  the  same 
stages  as  all  other  branches  of  medical  knowledge.  Prom  ignorance 
and  chaos  emerged  crude  ideas,  which  in  their  turn  gave  birth  to 
systematic  knowledge.  Let  us  hope  that  by  going  to  the  root  of  the 
matter,  by  a  thorough  and  complete  study  of  these  diseases,  we  shall  at 
length  reach  a  really  scientific  mastery  of  their  various  species  and  true 
nature. 

The  false  idea  that,  because  uterine  diseases  had  common  symptoms, 
they  must  also  share  a  common  nature,  led  to  equally  erroneous  con- 
sequences in  identical  treatment  for  all  cases.  The  differentiation  of 
their  various  kinds  will,  on  the  contrary,  teach  us  to  treat  them,  not 
all  alike,  but  each  by  a  special  method  founded  on  the  indications 
furnished  both  by  the  origin  and  manifestations  of  the  disease.  We 
must  therefore  master  the  symptoms  common  to  all  uterine  diseases, 
not  only  for  the  sake  of  a  general  diagnosis,  but  that  we  may  be  on  our 
guard  against  analogies  that  are  only  apparent,  and  may  recognise,  in 
spite  of  misleading  resemblances,  the  true  differences  that  characterise 
each  variety. 

The  interest  of  this  general  study  of  diseases  of  the  womb  is  thus 
intensified.  Our  diagnosis  will  not  be  formed  simply  by  the  considera- 
tion of  certain  symptoms  which  indicate  the  presence  of  uterine  mis- 
chief; it  will  depend  on  a  proper  interpretation  of  these  symptoms,  or  of 
groups  of  symptoms  variously  arranged,  as  the  pathognomonic  expres- 
sion of  each  type  of  disease.  So  also  we  shall  not  be  satisfied  with  a 
general  line  of  treatment,  but  shall  make  a  point  of  studying  each 
separate  indication,  so  that  from  the  character  of  the  chief  symptoms 
we  may  deduce  the  appropriate  remedies.  From  such  simultaneous 
study  of  diagnostic  signs  and  therapeutic  means  we  ought  to  acquire, 
on  the  one  hand,  a  comprehensive  knowledge  of  uterine  diseases,  and 
we  shall  also  have  prepared  for  ourselves  a  safe  pathway  with  many 
finger-posts,  to  guide  us  aright  as  to  the  diagnosis  and  treatment  of  each 
particular  malady. 

"  By  their  almost  latent  state,  their  great  variety  of  symptoms  (often 
very  transitory),  their  sympathetic  effects  on  all  parts  of  the  economy, 
and  their  immense  influence  on  the  nervous  system,  uterine  diseases 
are  peculiarly  apt  to  lead  medical  practitioners  into  errors  of  diagnosis.^' 
Thus  wrote  Lisfranc,  who  dedicated  seventy-four  pages  to  pointing  out 


DIAGNOSIS  97 

such  diagnostic  errors,  with  illustrations  from  his  own  observations.^  I 
have  myself  seen  mistakes  made  by  practitioners  of  excellent  standing 
which  would  have  been  simply  incredible  without  such  evidence.  Tor 
example,  I  remember  one  case  where  a  previous  pregnancy  was  asserted 
while  the  conical  cervix  ought  to  have  suggested  sterility.  I  have  seen 
cases  of  leucorrhoea  mistaken  for  blennorrhagia,  and  the  peace  of  house- 
holds consequently  destroyed. 

The  best  way  of  escaping  such  errors  is  to  understand  their  cause. 
It  is  certain  that  the  majority  of  medical  men  can  diagnose  the  diseases 
of  other  organs  better  than  those  of  the  uterus ;  and  hence  we  may  be 
sure  that  there  are  real  difficulties  in  the  way.  These  are  partly  due  to 
the  fact  that  the  uterine  symptoms  are  not  always  the  most  prominent, 
that  they  are  frequently  slowly  developed,  and  sometimes  do  not  attract 
the  patient^s  attention,  while  disorders  of  the  alimentary  canal  or 
nervous  system  demand  more  notice  and  cause  more  evident  suffering. 
How  often  is  one  consulted  for  neuralgia  or  hysteria;  for  symptoms 
manifested  in  the  stomach,  the  heart,  or  the  liver;  for  digestive 
troubles — anorexia,  nausea,  diarrhoea,  and  for  all  the  train  of  evils 
depending  on  poverty  of  blood — anaemia,  chlorosis,  emaciation  and 
exhaustion,  but  the  natural  and  symptomatic  manifestations  of  an  un- 
recognised uterine  malady  ! 

The  explanation  lies  in  the  fact  that  the  uterus  exercises  a  most 
powerful  influence  over  the  whole  economy,  and  that  very  often  an 
apparently  insignificant  disorder  affecting  this  organ  is  felt  throughout 
the  body  to  a  quite  disproportionate  extent,  causing  troubles  in  neigh- 
bouring organs,  functional  derangements  of  the  various  systems,  and  in 
fact  a  result  greatly  exceeding  its  cause.  Most  frequently  the  gravest 
effects  are  felt  in  the  general  health  and  not  in  local  symptoms.  Such 
appearances  may  naturally  mislead  the  invalid,  but  they  ought  rather  to 
put  a  skilled  physician  on  his  guard,  and  suggest  to  him  the  existence 
of  the  morbid  state  that  they  only  thinly  veil.  They  should  lead  him 
to  ask  questions  which  may  help  towards  the  confirmation  of  his 
suspicions  and  the  discovery  of  additional  local  symptoms,  which 
should  end  in  the  direct  examination  of  the  organs  in  which  disease 
really  centres. 

It  is  of  importance  to  proceed  step  by  step,  and  to  pass  from 
general  to  local  symptoms ;  to  ascertain  the  condition  of  the  principal 
functions  and  their  derangements,  before  proceeding  to  investigate  the 
troubles  more  immediately  connected  with  the  uterine  system.  In 
this  way  the  practitioner  not  only  provides  himself  with  the  guidance 
of  a  sure  clue  which  keeps  him  from  losing  himself  in  the  chaos  of 
morbid  conditions,  gradually  leads  him  away  from  mere  functional  and 
symptomatic  derangements,  and  brings  him  closer  to  the  original 
cause  of  all  these  evils ;  but  at  the  same  time  he  is  enabled  to  carry 
the  sufferer's  mind  along  with  his  own,  and  to  make  her  realise  the 
true  origin  of  her  troubles. 

It  is  essential  that  the  patient  should  be  led  steadily  to  the  convic- 
tion at  which  the  physician  has  already  arrived,  for  this  conviction  is 
'  Clinique  chirurgicale  de  la  Pitie,  vol.  ii,  p.  182.     Paris,  1842. 

7 


98  GENBEAL    SUKVEY    OP  UTERINE    DISEASES 

the  only  means  by  which  he  can  hope  to  make  her  understand  the 
necessity  for  a  local  examination  and  agree  to  submit  to  this  painful 
trial.  This  point  is  the  more  important,  as  a  woman^s  decision  on 
this  matter  will  be  entirely  governed  by  the  fact  that  she  is  or  is  not 
convinced  that  she  is  suffering  from  disease  of  the  womb.  Women 
are  so  much  afraid  of  polypi,  cancers,  and  ulcerations — which  sum  up 
their  ideas  of  all  uterine  maladies — that  the  reasonable  terror  inspired 
by  these  affections  will  not  only  remove  their  repugnance  to  an  exami- 
nation, but  will  make  them  earnestly  desire  it.  Even  the  less  sensible 
women  will  feel  their  instinct  of  modesty  overborne  by  their  desire  of 
self-preservation,  and  I  can  assert  that — putting  aside  the  members  of 
religious  orders^  among  whom  it  is  often  impossible  to  obtain  any 
examination  of  the  genital  organs — I  have  never  yet  met  with  one 
woman,  even  unmarried,  who  has  refused  to  allow  an  examination 
when  she  was  thoroughly  convinced  that  her  malady  was  really  in  the 
womb. 

Then  of  course  the  direct  exploration  by  sight  and  touch  reveals 
signs  absolutely  pathognomonic ;  and  these,  in  combination  with  the 
symptoms  already  noted,  enable  us  to  determine  absolutely  the  exact 
seat  and  form  and  usually  also  the  exact  nature  of  the  disease. 

I  believe  I  cannot  better  explain  the  various  steps  towards  a  dia- 
gnosis than  by  following  exactly  the  order  in  which  patients  should  be 
interrogated  and  examined.  Experience  has  taught  me  the  value  of 
such  a  method  in  teaching  a  tolerably  difficult  subject.  In  dogmatic 
teaching  synthesis  may  be  preferable,  but  in  chnical  instruction  I 
prefer  analysis. 

Let  us  imagine  a  patient  of  the  kind  most  commonly  met  with  ;  let 
us  first  ascertain  of  what  she  specially  complains ;  let  us  review  all  the 
more  general  symptoms  in  their  order  of  frequency,  and  then  let  us 
come  gradually  to  local  symptoms  ;  then  demonstrate  the  best  modes 
of  examination,  and  finally  enumerate  the  various  indications  which 
we  may  expect  to  find. 

All  general  and  local  symptoms  related  by  the  patient  or  observed 
by  the  physician,  without  direct  examination,  are  rational  or  sub- 
jective ;  they  form  a  basis  of  probability  or  presumption.  What  we 
learn  by  direct  examination  are  sensible  or  objective  symptoms ;  they 
form  a  basis  of  certainty.  The  latter  are  to  be  sought  only  subse- 
quently to  the  former,  unless  we  find  in  the  first  instance  sufficient 
reason  for  immediate  examination. 


Presumptive  Signs  Indicating  Uterine  Disease 

General  Symptoms. — Whenever  a  change  of  condition  as  well  as  of 
function  takes  place  in  the  womb,  as  at  puberty,  at  each  menstrual 
epoch,  during  pregnancy,  and  at  the  menopause,  there  is  a  tendency 
towards  a  morbid  uterine  condition  which  in  turn  will  react  painfuUy 
on  the  whole  system.  A  pathological  change  of  considerable  impor- 
tance may  take  place,  and  may  long  remain   unnoticed^  whilst  the 


PRESUMPTIVE    SIGNS    INDICATING    UTERINE    DISEASE        99 

most  insignificant  functional  disorder  is  sufficient  to  disturb  the  whole     I 
economy.     It  is  very  striking  to  observe  the  disproportionate  magni- 
tude of  this  general  disturbance  compared  to  the  insignificance  of  the 
change  which  has  produced  it. 

It  is  therefore  from  ignorance  as  well  as  from  modesty  that  the 
majority  of  women  suffering  from  chronic  disease  of  the  womb  complain 
of  symptoms  which  seem  to  indicate  a  malady  in  no  way  connected 
with  this  organ.  Some  complain  of  nervous  troubles,  giddiness  and 
neuralgia ;  others  of  nausea  and  of  disorders  of  digestion;  the  majority 
of  weakness  and  exhaustion.  In  short  there  are  almost  always  func- 
tional^'disturbances  of  the  nervous  and  digestive  systems,  which  in  turn 
tend  to  produce  various  morbid  cachexies,  just  as  in  the  beginning  of 
pregnancy  we  have  vomiting,  dyspepsia  and  nervous  disturbance,  and 
these  are  apt  to  be  followed  by  anaemia,  chlorosis  and  emaciation. 

But  we  must  remember  that  symptoms  can  do  no  more  than  sound 
the  tocsin  of  alarm ;  we  must  not  expect  them  to  indicate  precisely 
the  site  of  the  lesion,  and  still  less  to  explain  the  cause  of  the  suffering. 
We  must  therefore  first  ascertain  whether  these  pathological  con- 1  -^yvi/w 
ditions  are  symptomatic  or  idiopathic.  To  do  this  we  must  not  only  I 
assure  ourselves  of  organic  integrity  side  by  side  with  functional 
derangement,  but  we  must  endeavour  to  identify  the  original  cause  of 
disturbance,  and  to  fix  upon  any  special  indications  which  may  enable 
us  to  trace  up  the  connection  with  the  uterine  system.  In  studying 
general  symptoms  I  will  follow  the  usual  order  of  their  appearance. 

I.  Disorders  of  digestion. — Every  practitioner  must  have  had 
patients  who  came  to  consult  him  for  gastric  derangement  and  dys- 
pepsia, when  the  real  source  of  trouble  lay  in  the  womb ;  and  I  have 
known  such  cases  treated  by  distinguished  physicians  for  the  cure 
of  a  malady  that  never  existed.  Indeed,  this  whole  class  of  disorders — 
gastralgia,  nausea,  dyspepsia,  anorexia,  perverted  appetite,  oesophageal 
constriction,  the  globus  hystericus,  &c.,  &c. — these  are  of  all  others 
the  symptoms  which  most  frequently  accompany  uterine  diseases,  and 
more  especially  affections  of  the  body  of  the  womb.  In  such  cases 
these  alone  are  complained  of  because  these  alone  are  felt. 

The  first  and  most  common  of  such  derangements  is  an  increasing 
difficulty  of  gastric  digestion.  This  is  not  a  true  dyspepsia.  There  is 
a  good  appetite,  and  the  intestinal  functions  are  healthy ;  but  gastric 
digestion  is  slow,  and  is  accompanied  by  discomfort  and  epigastric 
tenderness,  with  distension  and  a  sense  of  suffocation  from  the  flatu- 
lent development  of  gases,  which  lead  to  frequent  inodorous  eructa- 
tions, obliging  women  to  loosen  their  dresses  and  to  avoid  the  least 
pressure  on  the  epigastrium.  Sometimes  a  desire  for  food  returns 
very  soon  after  a  meal,  but  this  is  purely  factitious.  Digestive  inertia 
and  pain  is  often  succeeded  by  real  dyspepsia  of  a  nervous  type,  in- 
volving much  suffering  and  great  delay  in  tlie  accomplishment  of  diges- 
tion, with  sensations  of  weight  and  pain,  swelling  at  the  epigastrium, 
bitter  regurgitation,  headache,  exhaustion,  incapacity  for  work,  and  a 
sense  of  sinking  which  cannot  be  removed  by  food.  This  type  of 
dyspepsia  is    purely  nervous  and    symptomatic  of    uterine   disease. 


100       GENERAL  SURVEY  OP  UTERINE  DISEASES 

while  it  has  not  the  characteristics  of  true  idiopathic  dyspepsia.  The 
tongue  is  clean  and  normal,  not  dry,  neither  edged  nor  spotted  with 
red,  and  rarely  furred.  This  in  itself  is  an  important  diagnostic  sign. 
In  the  third  stage  this  kind  of  indigestion  is  marked  with  want  of 
appetite  and  a  tendency  to  nausea,  sometimes  with  actual  vomiting  of 
food,  either  before,  during,  or  after  meals.  This  symptom  occasionally 
leads  the  sufferer  to  believe  herself  pregnant.  Digestive  troubles  of 
this  kind  do  not  merely  indicate  uterine  disease;  they  suggest  further, 
that  it  is  the  body  and  not  the  neck  of  the  womb  that  is  involved. 
Ovarian  disease  is  also  more  apt  than  affections  of  the  cervix  to  produce 
these  digestive  and  nervous  derangements.  In  addition  to  these  we 
may  find,  though  more  rarely,  a  derangement  of  the  biliary  secretion, 
described  by  Bennet^  and  Aran.^  This  affection  causes  enlargement  of 
the  liver  and  gall-bladder,  and  produces  fits  of  sharp  pain,  which 
begin  in  the  hepatic  region  but  extend  over  the  chest,  breast  and 
rio-ht  shoulder.  They  are  accompanied  by  bilious  vomiting  and  diar- 
rhoea, with  excessive  sensibility  in  the  epigastric  and  right  hypochon- 
driac regions.  These  attacks  occur  most  frequently  a  few  days  before 
the  menstrual  period,  and  are  accompanied  very  often  by  slight  jaun- 
dice. Bennet  thinks  they  are  purely  symptomatic  of  dyspepsia,  but 
Aran  considers  them  to  be  true  hepatic  colics,  due  to  a  biKary 
lithiasis,  which  seems  connected  with  urinary  lithiasis,  especially  at 
the  menopause. 

II.  Nervous  disorders  may  be  produced  by  uterine  disease  (1) 
directly,  i.  e.  by  sympathetic  irritation  of  the  nervous  system  ;  (2)  in- 
directly, by  means  of  impoverishment  of  the  blood  and  general  con- 
stitutional debility.  Indeed,  these  morbid  phenomena  may  alternately 
act  as  cause  and  effect,  for  the  poverty  of  blood  may  be  due  to  defects 
of  innervation  as  well  as  of  digestion.  They  react  both  on  the  sensory 
and  motor  functions,  whether  in  the  domain  of  voluntary  or  involuntary 
organic  life.  Large  account  must  also  be  taken  of  disorders  of  sensa- 
tion, which  may  take  the  form  of  (1)  anaesthesia;  (2)  visceral 
neuralgias  ;  (3)  neuralgia  of  the  usual  type. 

(1)  Ancestkesia  may  affect  many  parts  of  the  epidermis,  but  is 
especially  frequent  in  the  lower  limbs.  Sometimes  it  invades  the 
genital  organs,  the  clitoris  and  vagina,  which  are  then  no  longer 
capable  of  being  excited,  and  even  the  uterus  itself,  which  falls  into  a 
state  of  inertia,  the  sexual  life  of  the  woman  being  thus  prematurely 
brought  to  a  close.  I  have  seen  several  examples  of  this  kind,  where 
sexual  desire  and  pleasure  in  coitus  were  entirely  lost  after  the  begin- 
ning of  uterine  disease. 

(2)  These  nervous  affections  attack  not  only  the  bladder  and  rectum, 
which  are  close  to  the  uterus,  but  also  remote  organs,  such  as  the  liver, 
the  intestinal  canal,  the  stomach,  and  more  especially  the  heart,  so 

^  A  practical  treatise  on  Inflammation  of  the  Uterus,  its  Cervix  and 
Appendages,  and  on  its  connection  with  other  JJteHne  Diseases,  4th  edition. 
London,  1861,  p.  119. 

^  Legons  cliniques  sur  les  maladies  de  I'lderus  et  de  ses  annexes.  Paris, 
1858,  p.  141. 


PEESUMPTIVE    SIGNS    INDICATING    UTEEINB    DISEASE      101 

that  cardiac  suffering  and  palpitation  alarm  the  patient  extremely,  and 
make  her  fear  the  existence  of  an  aneurism  or  other  organic  lesion. 

(3)  Neuralgia,  however,  is  the  commonest  of  all  these  disorders, 
not  only  in  the  lumbar  and  abdominal  regions,  where  it  might  possibly 
be  supposed  to  be  propagated  from  the  uterus,  but  also  in  more  distant 
parts,  and  specially  intercostal  neuralgia  on  the  left  side,  which  makes 
the  patient  fear  that  her  heart  is  affected,  and  trifacial  neuralgia,  which 
causes  the  sensation  of  a  nail  being  driven  into  the  skull  in  the  parietal 
region,  as  described  by  Sydenham. 

Intercostal  neuralgia  is  often  associated  with  pain  in  the  breast, 
shoulder  and  arm  of  the  same  side,  and  if  with  lumbago  sciatica  and 
facial  neuralgia  it  may  suggest  to  the  patient  the  fear  of  hemiplegia.  It  is 
not  rare  to  find  either  hyperaesthesia  or  anaesthesia  affecting  one  half  of 
the  body  only,  being,  in  fact,  a  kind  of  hysteric  hemiplegia  affecting 
sensation,  as  in  other  cases  it  may  affect  motion. 

Uterine  disease  may  also  manifest  itself  by  sympathetic  pains  in  the 
breast  extending  to  the  axillae  and  causing  a  feeling  of  swelling  and  a 
particular  kind  of  erethism  often  experienced  during  menstruation  and 
pregnancy.  These  sympathetic  pains  in  the  breast  are  very  common, 
especially  during  menstruation,  sometimes  sharp,  sometimes  dull,  the 
mammary  glands  being  occasionally  so  swollen  that  it  is  impossible 
to  bring  the  arm  close  to  the  side. 

Hysteria,  which  seems  to  be  a  natural  point  of  transition  between 
disorders  of  sensation  and  of  motion,  since  it  includes  both,  is  not 
exclusively  connected  with  the  uterus  or  the  ovaries,  nor  even  with  the 
whole  genital  system.  It  is  a  chronic  nervous  affection  characterised 
by  two  kinds  of  symptoms ;  on  the  one  hand  we  have  various  perma- 
nent symptoms,  such  as  anaesthesia,  or  it  may  be  hyperaesthesia,  or 
neuralgia,  spasms,  convulsive  cough,  or  paralysis  of  different  kinds; 
on  the  other  hand  we  have  intermittent  symptoms,  attacks  coming  on 
at  irregular  intervals,  characterised  by  the  globus  hystericus,  a  sensation 
of  suffocation,  or  a  loss  of  consciousness  accompanied  by  various  dis- 
orders of  sensation  and  motion,  and  generally  terminating  in  a  fit  of 
crying  or  in  polyuria.  This  nervous  affection  often  accompanies  uterine 
disease,  but  it  may  be  developed  independently  of  this  cause;  indeed, 
physicians  of  great  authority  tell  us  it  may  be  met  with  in  men. 
Nevertheless,  it  cannot  be  denied  that  the  uterus  or  ovary,  whether  or 
not  in  a  normal  condition,  is  most  generally  the  starting-point,  if  not 
the  seat,  of  this  affection.  We  need  no  further  proof  of  this  than  the 
extreme  frequency  of  hysteria  among  women,  especially  among  those 
of  a  passionate  nature  who  exercise  self-restraint;  and  the  same  thing 
is  demonstrated  by  the  voluptuous  character  of  the  convulsive  move- 
ments accompanying  such  attacks,  as  regards  not  only  those  of  the 
arms  and  eyes,  but  especially  of  the  pelvis,  even  in  the  case  of  virgins 
wholly  ignorant  of  sexual  relations.  If,  helped  by  the  light  which 
recent  researches  have  thrown  on  the  physiology  of  the  nervous 
system,  we  endeavour  to  discover  the  relative  share  of  influence 
exercised  by  the  nerves  and  by  the  uterus  on  hysteria,  we  must  admit 
that  the  disease  is  really  a  neurosis,  that  is  to  say,  that  it  is  due  to  a 


102  GENERAL    SURVEY    OP   UTERINE    DISEASES 

general  derangement  of  innervation,  in  which  the  whole  nervous 
system  partakes  with  effects  varying  in  form  and  in  degree  according 
to  the  exciting  cause  and  to  the  special  idiosyncrasy  in  each  case.^ 
But  we  must  remember  that  these  symptoms,  so  varied  in  detail  and 
yet  so  similar  as  a  whole,  are  only  manifestations  of  the  reflex  action 
of  brain  or  spinal  cord,  the  starting-point  having  been  irritation  in 
some  other  organ,  generally  in  the  generative  system.  This  irritation 
and  its  influence  transmitted  to  the  nervous  centres  (analogous  to  the 
O/Ura  epile^tica)  is  often  overlooked,  while  yet  producing  endless 
phenomena  of  sensation  or  motion,  affecting  sometimes  the  whole 
economy  and  sometimes  only  the  various  parts  of  the  reproductive 
system  in  which  it  took  its  rise.  Thus  hysteria  is  not  properly 
speaking  a  disease  of  the  uterus  or  ovaries,  but  functional  derange- 
ments of  these  organs  may  be  an  exciting  if  not  a  primary  cause  of  it. 
I  say  functional  derangement  rather  than  disease ;  for  usually  it  is 
some  condition  of  pain,  excitement,  or  irritation,  nervous  or  vascular, 
in  some  part  of  the  genital  organs  that  forms  the  starting  point  of 
hysteria  in  pale,  nervous  and  emaciated  women,  who  already  are  pre- 
disposed to  it.  Sometimes  marriage  is  sufficient  to  develop  this  con- 
dition, which  in  its  turn  produces  hysteria. 

On  the  other  hand,  when  there  is  real  uterine  disease  the  patient 
may  be  irritable,  neuralgic  and  even  partially  paralysed,  but  she  will 
seldom  complain  of  the  globus  hystericiis,  or  suffer  from  any  really 
serious  hysterical  fits  or  convulsions.  In  fact  true  hysteria  is  one  of 
the  rarest  of  the  nervous  disorders  occurring  as  general  symptoms  of 
uterine  disease. 

Spasms,  tonic  or  clonic,  muscular  rigidity,  contractions  or  convul- 
sions, may  occur  incidentally  more  frequently  in  the  involuntary  than 
in  the  voluntary  muscular  system.  May  not  vesical  tenesmus, 
vomiting,  spasmodic  dyspnoea,  cardiac  palpitations,  &c.,  be  attributed 
to  this  cause  ?  Of  such  nature  also  is  the  little  dry  cough  which 
Ajan  2  calls  '^  the  uterine  cough,"  which  differs  essentially  from  the 
loud  and  noisy  hysterical  cough  that  somewhat  resembles  pertussis, 
and  which  I  think  Trousseau  ^  is  right  in  attributing  to  the  convulsive 
motion  of  the  muscles  of  the  larynx  and  diaphragm.  This  uterine 
cough  is  rare  except  in  cases  of  great  debility  and  exhaustion ;  and 
consequently  it  is  a  symptom  which  should  arrest  the  attention  of  the 
physician.  He  must  decide  whether  it  is  nervous  and  merely  sym- 
ptomatic of  uterine  disease,  or  due  to  the  commencement  of  pul- 
monary tuberculosis. 

^  Coste,  Be  Vhysiirie  consideree  principalem,ent  an  point  de  vue  de  sa 
nature  et  de  ses  causes.  These  de  Montpellier,  1863,  No.  6.  See  also  Rouget, 
Physiologie  des  actions  reflexes,  introduction  to  the  French  translation  of 
Paralysis  of  the  Lower  Limbs,  by  Brown- Sequard,  1864.  And  Brown-Sequard, 
Arch.  gen.  de  medecine,  January,  1856 ;  Causes  organiques  et  mode  de  pro- 
duction des  affections  dites  hysteriques.  Gazette  medicale  de  Paris,  1846  ; 
Legons  sur  les  maladies  du  systeme  nerveux,  Bourneville,  4^  fascicule.  Paris, 
1873. 

2  Op.  cit.,  p.  146. 

^  Clinique  med.  de  I'Sotel-Dieu  de  Paris,  i.  ii,  p.  205,  2^  edit. 


PRESUMPTIVE    SIGNS    INDICATING    UTERINE    DISEASE       103 

Motor  paralysis  is  very  rare  as  a  nervous  symptom  of  uterine  dis- 
ease. Aran  ^  has  denied  its  existence.  It  certainly  must  not  be  con- 
founded with  a  numbness  of  the  side  of  the  body  corresponding  to  a 
lesion  of  the  generative  system,  nor  with  the  immobility  to  which  a 
patient  may  be  driven  by  the  intense  pain  occasioned  by  the  slightest 
movement ;  nor  even  with  more  or  less  complete  paralysis  of  the  lower 
limbs,  which  may  arise  from  mischief  in  the  pelvis  causing  compression 
of  the  great  nervous  trunks.  But  besides  these  direct  results  of 
organic  lesions  acting  mechanically  on  those  parts  of  the  nervous 
system  with  which  they  are  in  contact,  we  may  have  indirect  and 
sympathetic  disturbance  manifested  in  the  motor  nerves. 

No  one  doubts  the  existence  of  hysterical  paralysis  i  why  may  we 
not  have  similar  states  produced  by  a  suffering  condition  of  the  uterus 
and  ovaries  which  could  itself  develop  hysteria  ?  I  have  seen  two 
very  remarkable  instances,  one  of  hysterical  and  the  other  of  uterine 
paraplegia.  The  paralysis  need  not  be  general,  nor  affecting  the  upper 
limbs,  as  Aran  contends,  in  order  to  be  regarded  as  sympathetic. 
Indeed,  a  reflex  paralysis,  starting  from  the  uterus,  is  more  likely  to 
affect  the  lower  parts  of  the  body.  Lisfranc^  mentions  the  case  of  a 
lady  suffering  from  paraplegia,  who  had  been  treated  without  benefit 
for  a  supposed  affection  of  the  spinal  cord,  but  whose  condition  began 
to  improve  only  when  attention  was  paid  to  a  chronic  metritis,  which 
was  the  real  cause  of  the  paralysis.  He  gives  another  case  of  para- 
plegia, where  the  cure  of  this  affection  kept  step  exactly  with  the  relief 
of  the  uterine  malady.  Nonat^  relates  several  similar  cases,  and  shows 
that  when  the  uterine  disease  is  unilateral  the  paralysis  is  so  also. 
These  last  cases  seem  to  me  to  present  some  difficulties.  I  must  refer 
readers  to  his  own  work,  and  also  to  the  theses  of  his  pupils, 
Esnault*  and  Tallin.^  Brown-Sequard^  refers  to  these  cases,  and 
mentions  having  been  consulted  in  1855  by  a  young  lady  for  extreme 
weakness,  amounting  to  paraplegia,  at  each  menstrual  period.  Sen- 
sibility was  normal ;  there  were  no  symptoms  of  hysteria  and  no  para- 
lysis of  the  bladder  or  rectum.  There  was  dysmenorrhoea,  congestion 
and  anteflexion  of  the  uterus,  which  was  enlarged  and  very  sensitive, 
the  tenderness  extending  to  the  broad  ligaments,  &c.  The  womb  was 
supported  by  an  abdominal  bandage,  and  in  a  few  days  there  was  a 
marked  improvement;  in  less  than  a  fortnight  the  paralysis  disap- 
peared, though  it  had  lasted  for  six  months  and  had  been  treated  by 
strychnia,  galvanism  and  hydropathy,  as  well  as  iron  and  other  tonics. 
At  present  I  have  a  young  girl  under  my  care  who  had  sufl'ered  for 

1  Op.  cit.,  p.  147. 

^  Clinique  chirurgicale  de  la  Pitie,  vol  ii,  p.  199.     Paris,  1842. 

^  Traite  pratique  des  maladies  de  Vuterus  et  de  ses  annexes,  p.  381.  Paris, 
1860. 

■*  Des  paralysies  symptomatiques  de  la  metrite  et  du  phlegmon  periuterin. 
These  de  Paris,  1857,  No.  206. 

*  Des  paralysies  sympathiques  des  maladies  de  Vuterus  et  de  ses  annexes. 
These  de  Paris,  1858,  No.  33.  _ 

*  Lessons  on  the  Diagnosis  and  Treatment  of  the  Principal  Forms  of 
Paralysis  of  the  Lower  Extremities,    London,  1861,  p.  11. 


104  GENEEAL    SURVEY    OF   UTEEINE    DISEASES 

more  than  a  year  from  violent  hypogastric  pains^  sometimes  associated 
with  hysteralgia  and  purulent  vaginal  leucorrhoea,  and  at  other  times 
complicated  with  similar  symptoms  in  the  rectum  and  bladder,  with 
retention  of  urine,  which  was  loaded  with  deposits.  This  condition 
was  accompanied  by  complete  paralysis  of  the  lower  limbs,  which  with- 
stood every  kind  of  treatment,  general  and  local,  but  is  now  disap- 
pearing as  the  pelvic  and  uterine  pains  are  gradually  yielding  to  the 
influence  of  atropine  injected  subcutaneously  into  the  hypogastrium. 
Not  long  ago  I  was  consulted  by  a  lady  affected  with  paraplegia,  who 
was  on  her  way  to  Balaruc ;  a  chronic  metritis  was  discovered,  appro- 
priately treated  and  cured,  the  paralysis  also  disappearing  without  the 
help  of  the  Balaruc  waters.  Hunt,  Romberg,  Wolf,  Mayer  and 
others  have  mentioned  similar  cases.  Brown- Sequard  asks,  What 
causes  such  paraplegia?  We  cannot  admit  that  in  the  majority  of 
cases  it  is  due  to  compression  of  the  nerves  of  the  lower  limbs, 
because  the  increased  size  of  the  organ  is  not  sufficient  to  produce 
such  an  effect.  Besides,  sensibility  is  very  little,  if  at  all,  affected. 
We  must  therefore  conclude  that  the  uterine  disease  produces  the 
paraplegia  by  a  special  action  on  the  spinal  cord,  and  that,  therefore, 
such  paraplegia  has  all  the  characters  of  reflex  paralysis.  In  such 
cases  the  cure  of  the  paralysis  must  depend  on  that  of  the  uterine 
malady,  and  our  main  duty  is,  therefore,  to  be  able  to  diagnose  this 
latter  disease  and  treat  it  appropriately. 

III.  Disorders  of  nutrition. — Derangements  of  the  digestive  and 
nervous  systems  naturally  bring  about  an  impoverished  state  of  the 
blood  and  impaired  nutrition.  Anaemia,  chlorosis  and  general 
debility  are,  therefore,  constantly  present  in  women  who  have  been 
ill  for  some  months,  and  may  be  taken  as  general  symptoms  of  uterine 
disease. 

Chlorosis  occurs  specially  in  ill-nourished  young  women  who  have 
probably  already  suffered  from  it  at  puberty  and  during  pregnancy, 
so  that  it  is  rather  developed  than  originated  by  the  uterine  disease. 

AncBmia  is  most  common  among  older  women,  among  those 
suffering  from  serious  diseases,  such  as  cancer,  fibroid  tumours 
and  polypi,  where  repeated  and  profuse  haemorrhages  have  occurred.  It 
is  less  a  morbid  affection  than  a  direct  or  indirect  result  of  the  uterine 
malady.  Hepeated  losses  have  impoverished  the  blood  and  deprived 
the  economy  of  needful  materials  for  repair ;  suppuration  and  insuffi- 
cient assimilation  have  weakened  the  patient ;  these  are  followed  by 
loss  of  colour  in  the  skin,  transparency  of  tissues,  local  cedema,  a 
frequent  weak  pulse,  general  debility  and,  in  fact,  symptoms  resem- 
bling those  that  follow  after  delivery  or  after  some  serious  operation. 

Chlorosis,  anaemia,  or  chloro-ansemia  are  not  only  accompanied  by 
general  debility,  but  by  constantly  increasing  emaciation,  until  the 
dyspepsia  and  uterine  disease  are  properly  treated.  Even  where  no 
special  pain  exists  the  patient  acquires  a  very  characteristic  attitude, 
constantly  stooping  forwards,  the  head  and  limbs  bent  in  a  manner 
usually  seen  only  in  old  age.  The  features  are  drawn  and  have  a 
look  of  suffering,  which  is  all  the  more  striking  because  the  patient  is 


PRESUMPTIVE    SIGNS    INDICATING    UTERINE    DISEASE       105 

SO  thin ;  the  flesh  is  soft  and  flabby,  the  countenance  wanting  in 
expression,  the  complexion  pale  and  faded,  especially  where  there  has 
been  long  standing  and  abundant  leucorrhoea ;  this  paleness  with  loss 
of  flesh  and  earthy  complexion  is  different  from  the  colourlessness  of 
ansemia,  the  sickly  green  hue  of  chlorosis,  and  the  pale  yeUow  of 
cancer.  It  is  to  this  very  characteristic  appearance  that  we  give  the 
name  oi fades  uterina. 

Emaciation  does  not  always  exist ;  on  the  contrary,  there  is  some- 
times corpulency.  This  is  chiefly  the  case  among  those  women  in 
whom  amenorrhoea  takes  the  place  of  leucorrhcea  or  hsemorrhage  ;  and 
the  constitution  seems  to  get  accustomed  to  the  change.  Is  it  pos- 
sible that  the  blood  which  should  have  formed  the  catamenia  is  used 
up  in  the  economy  to  produce  this  unhealthy  stoutness  ?  We  cannot  ■ 
affirm  that  it  is  so,  but  there  is  no  doubt  of  the  embonpoint  which 
becomes  obesity,  and  which  leads  some  women  to  believe  themselves 
pregnant ;  whilst  others,  when  sufi^ering  greatly,  are  forced  to  listen  to 
the  congratulations  of  friends  on  their  excellent  health.  As  the 
uterine  disease  becomes  cured  this  unhealthy  stoutness  disappears, 
and  with  it  its  various  accompanying  discomforts.  Should  the  obesity 
persist  it  may  be  treated  by  vapour  baths,  resolvents,  tonics,  exercise, 
diet  of  roast  meat  and  green  vegetables,  in  addition  to  the  admin- 
istration oifucus  vesiculosus,  and  these  measures  will  generally  bring 
the  body  back  to  its  normal  condition. 

Local  Symptoms. — These  are  found  in  the  neighbouring  organs,  or 
in  the  uterus  itself  or  its  appendages. 

1.  In  the  neighbouring  organs. — The  rectum  and  bladder  will 
almost  always  be  found  affected. 

A.  Functional  derangements  of  the  rectum  may  accompany  disturb- 
ance of  the  rest  of  the  alimentary  canal.  Though  frequent  they  do 
not  always  exist ;  and  sometimes  instead  of  resulting  from  uterine  dis- 
ease they  may  produce  it.  If  coincident,  the  two  react  upon  and 
aggravate  each  other.  Many  women  who  are  habitually  constipated 
have  diarrhoea  just  before  the  menstrual  period,  or  during  its  course. 
Tliough  this  symptom  requires  no  treatment  it  is  worthy  of  notice,  as 
showing  the  close  inter-dependence  of  the  various  pelvic  organs. 
Another  very  important  point  is  habitual  constipation,  which  is  so 
common  among  women  that  in  certain  cases  it  may  be  looked  on  as 
the  cause  of  the  uterine  malady.  We  must  therefore  find  out  whether 
the  constipation  was  habitual  and  to  what  extent  it  existed  before 
the  disease  of  the  womb.  There  are  cases  in  which  it  has  neither 
increased  nor  diminished  since  that  period,  in  others  it  has  increased 
so  much  that  it  helps  to  keep  up  and  continue  the  uterine  disturbance 
by  the  irritation  and  congestion  which  it  causes  in  the  pelvis. 

Constipation  does  not  necessarily  accompany  uterine  disease.  The 
derangement  of  the  digestive  functions  may  produce  diarrhoea;  but 
this  is  not  common  and  is  generally  followed  by  constipation.  Con- 
stipation is  all  the  more  frequent  because  it  may  be  perpetuated  by  a 
mechanical  cause.  In  prolapsus  and  various  displacements,  especially 
retroversion  and  retroflexion,  as  well  as  in  cases  of  tumours  (whether 


106  GENERAL    SURVEY    OE   UTERINE   DISEASES 

uterine,  periuterine,  or  ovarian),  the  rectum  suffers  from  pressure 
which  impedes  the  circulation.  In  cases  of  metritis,  uterine  catarrh, 
ovarian  or  periuterine  inflammation,  congestion  of  the  rectum  is  not 
due  only  to  blood  stasis  but  to  an  extension  of  the  inflammation,  in 
which  case  diarrhoea  sometimes  alternates  with  constipation.  How- 
ever, the  first  effect  of  congestion  is  generally  obstinate  constipation, 
which  is  one  of  the  most  common  and  most  serious  symptoms  of  every 
uterine  disease.  The  mass  of  hardened  scybala  can  be  evacuated  only 
after  enemata  and  repeated  efforts,  and  the  fseces  are  often  coated 
with  mucus,  a  sign  of  enteric  inflammation.  The  constipation  may 
last  for  two  or  three  weeks  or  end  in  painful  diarrhoea  with  tenesmus, 
lasting  several  days ;  and  sometimes  even  this  will  not  occur  without 
•the  use  of  purgatives.  The  accumulation  of  fseces  and  consequent 
distension  of  the  intestine  bring  on  a  kind  of  paralysis,  the  retained 
mass  becomes  partly  decomposed  and  some  of  its  elements  may  be 
reabsorbed.  The  effect  of  this  form  of  blood  poisoning,  to  which 
Barnes  gives  the  name  of  Copramia,  may  be  seen  in  the  sallow,  dirty 
hue  of  the  skin,  the  ill-smelling  cutaneous  secretions,  in  dyspepsia, 
flatulence,  pyrosis,  and  in  fact  in  endless  disorders  of  nutrition  and 
innervation.  Sometimes  the  paralysis  and  obstruction  of  the  intestine 
go  so  far  as  to  resist  all  treatment ;  I  have  seen  several  women  die 
from  simple  constipation.  In  spite  of  constipation  the  sufferer  may 
be  tormented  by  an  urgent  desire  to  go  to  stool,  owing  to  pressure 
being  exercised  on  the  rectum  by  the  uterine  tumour.  This  desire 
becomes  so  strong  that  women  make  violent  expulsive  efforts,  the 
only  result  of  which  is  the  excretion  of  some  bloody  mucus,  with 
tenesmus  and  intolerable  straining.  In  this  way  habitual  constipation 
increases  uterine  disease  both  directly  and  indirectly.  It  almost 
always  leads  to  hsemorrhoids,  anal  fissure,  contraction  of  the  sphincter 
and  violent  pains  during  defsecation,  which  may  persist  for  a  long 
time  afterwards.  Such  violent  efforts  cannot  be  made  without  painful 
reaction  on  the  uterus,  and  the  patient  dreads  the  effects  so  much  that 
she  is  apt  to  let  the  constipation  go  on  unless  constantly  watched. 

B.  Derangements  in  the  functions  of  the  bladder  and  urinary  system 
are  various.  The  urine  is  often  clouded,  especially  in  the  case  of 
patients  who  have  a  displacement  or  hypertrophy  of  the  uterus,  which 
then  presses  on  the  bladder  or  urethral  canal;  particularly  when  any 
new  irritation  arises  in  the  womb,  or  an  increase  of  old  inflammatory 
symptoms  reacts  on  the  bladder.  Patients  usually  complain  of 
frequent  desire  for  micturition,  often  accompanied  with  dysuria  and 
sometimes  with  strangury  and  hsematuria. 

The  bladder  in  fact  often  shares  the  morbid  condition  of  the 
uterus ;  there  may  be  congestion  or  even  inflammation,  and  perhaps 
catarrh  of  the  mucous  membrane;  the  urethra  may  be  red,  swollen 
and  bleeding ;  the  meati:^  congested  and  inflamed,  and  sometimes  the 
seat  of  small  vascular  tumours  of  which  I  shall  speak  subsequently. 
Any  pressure  on  the  bladder  from  the  abdominal  or  pelvic  viscera  is 
very  painful.  The  state  of  the  urine  corresponds  to  these  morbid 
conditions  and  requires  examination.     We  find  more  or  less  viscous. 


PEESUMPTIVE    SIGNS    INDICATING    UTERINE    DISEASE       107 

flaky,  mucous,  or  muco- purulent  deposits,  which  may  coincide  or 
alternate  with  deposits  of  white  powdery  triple  phosphates.  These 
muco-purulent  and  saline  deposits  are  signs  of  vesical  catarrh  which 
often  accompanies  uterine  catarrh.  Is  Aran  right  in  thinking  that 
much  of  the  pain  felt  by  women  suffering  from  uterine  disease  is  due 
to  these  deposits  and  to  the  irritation  caused  by  their  presence  in  the 
bladder  and  their  passage  through  the  urethra?  Catarrh  of  the 
bladder  with  irritation  and  inflammation  of  its  mucous  membrane  and 
that  of  the  urethra  is  a  still  more  likely  cause  of  much  suffering. 

Sometimes  the  abnormal  condition  of  the  urine  is  due  to  the  kidney 
itself.  The  secretion  may  not  only  be  very  much  increased  under  the 
influence  of  violent  pain  or  hysteria,  giving  rise  to  the  excretion  of  a 
large  quantity  of  transparent  "  nervous^^  urine,  but  the  secretion  may 
itself  be  altered,  containing  brick-red  deposits  of  uric  acid  or  urates. 
There  is  sometimes  a  tendency  to  the  renal  lithiasis  to  which  I  have 
already  called  attention  as  being  coincident  with  hepatic  lithiasis.  In 
these  cases,  it  seems  to  me,  there  is  a  rheumatic  if  not  a  gouty 
diathesis. 

II.  Symptoms  in  the  uterus. — It  is  desirable  to  ascertain  at  once 
how  the  various  reproductive  functions  have  been  performed,  especially 
menstruation  and  pregnancy.  As  regards  menstruation,  we  must  learn 
the  date  of  its  appearance,  the  character  of  each  monthly  period  and 
its  frequency  and  duration,  the  quantity  of  the  discharge,  and  the 
presence  or  absence  of  pain,  with  any  particulars  relating  to  the  meno- 
pause. If  dysmenorrhoea  has  existed  from  the  first  it  suggests  me- 
chanical obstruction,  whereas  if  it  supervened  after  marriage  or  after 
miscarriage  it  is  more  probably  due  to  cervicitis. 

It  is  important  to  learn  everything  relating  \,q previous  pregnancies ^ 
as  well  as  to  each  delivery. 

Sterility  is  a  fact  of  still  greater  importance  in  the  history  of  uterine 
disease.  If  a  woman  has  been  married  for  several  years  without  having 
become  pregnant  the  probability  is  that  something  is  wrong;  there 
may  be  some  malformation,  or  the  sterility  may  be  due  to  functional 
disturbance  or  to  disease.  In  nine  cases  out  of  ten  I  have  discovered 
the  cause  of  the  sterility  in  a  malformation,  or  in  a  morbid  condition 
of  the  cervix,  and  very  frequently  I  have  been  able  to  remedy  it. 
Uterine  symptoms  are  of  two  kinds — pain  and  excessive  discharges. 
Fain  is  the  cry  of  the  suffering  organ.  Of  all  local  symptoms  it 
is  the  first  to  attract  attention.  It  is,  however,  sometimes  absent ; 
but  even  in  such  cases  it  can  be  elicited  by  slight  causes,  and  it  is 
always  of  great  importance.  We  must  study  pain  from  three  points 
of  view — 1.  Its  form  of  expression.  2.  Its  seat.  3.  Its  type. 
When  studying  its  form  and  mode  of  production  we  must  distinguish 
between  spontaneous  pain  and  that  artificially  elicited. 

Spontaneous  pain  is  rare  if  we  limit  the  term  to  pain  caused  directly 
by  organic  disease,  but  we  ought  to  include  pains  induced  by  changes 
of  posture  which  give  rise  to  tension.  Spontaneous  pain  does,  how- 
ever, occur  frequently  enough,  even  when  the  patient  is  in  bed  with  all 
the  muscles  at  rest  and  with  no  exciting  cause  dependent  on  neigh- 


108  GENERAL    SURVEY    OF  UTERINE    DISEASES 

bouring  organs.  Such  pain  is  almost  always  the  symptom  of  acute 
disease  and  generally  of  inflammation,  such  as  occurs  in  acute  hy- 
persemia,  congestion,  metritis,  or  ovaritis  (whether  puerperal  or  not), 
but  most  especially  in  perimetritis  aud  hematocele.  In  some  cases 
this  pain  persists,  even  after  the  disease  has  passed  into  a  chronic 
state ;  but  as  a  rule  spontaneous  pain,  strictly  speaking,  disappears 
at  this  stage,  and  is  only  excited  by  pressure  or  concussion  dependent 
on  movements.  Although  patients  generally  suffer  least  when  in  bed, 
there  are  instances  where  less  pain  is  felt  when  walking  or  standing. 
When  the  dorsal  decubitus  causes  pain  we  may  suspect  retroversion, 
retroflexion,  a  tumour,  or  a  retro-uterine  hematocele.  Many  patients 
suffering  from  chronic  metritis  or  congestion,  or  even  from  simple 
hypertrophy  with  relaxation  of  the  uterine  ligaments,  experience  con- 
siderable pelvic  pain  when  lying  down,  especially  if  the  bed  slopes 
downwards  towards  the  foot.  I  have  known  several  invalids  who,  not 
content  with  making  the  bed  quite  horizontal,  have  instinctively  taken 
the  precaution  of  placing  a  pillow  under  the  nates,  so  that,  the  pelvis 
being  higher  than  the  shoulders,  the  uterus  escapes  all  pressure  from 
the  abdominal  viscera.  The  lateral  decubitus,  with  semi- flexion  of  the 
limbs,  is  sometimes  adopted  to  avoid  the  pain  referred  to,  but  this 
lateral  position  may  cause  other  pains.  If  these  are  felt  on  the  side  on 
which  the  patient  is  lying  the  lesion  will  be  there  also,  whether  its 
seat  be  in  the  ovary,  uterus,  or  connective  tissue,  the  pain  being  pro- 
duced by  pressure  on  organs  extremely  sensitive  from  their  patholo- 
gical state  and  exposed  by  their  position  to  pressure  from  neighbour- 
ing viscera.  If,  on  the  contrary,  pain  is  felt  in  the  other  side,  it  is  due 
either  to  the  dragging  of  the  diseased  uterus  on  the  ligaments  and 
appendages  of  that  side,  or  to  an  inflammatory  condition  with  abnormal 
adhesions,  in  which  case  it  may  depend  on  dragging  caused  even  by 
the  weight  of  a  healthy  uterus.  Some  patients  find  that  the  least 
fatiguing  position  is  that  of  pronation — either  lying  on  the  stomach 
or  on  elbows  and  knees ;  this  is  almost  a  certain  sign  of  retroflexion. 
Spontaneous  pain  may  be  felt  more  in  sitting  than  in  lying,  as  in  cases 
of  uterine  hypertrophy,  hematocele,  or  perimetritis.  The  patient 
cannot  remain  seated  for  long  without  experiencing  a  painful  sensation 
at  the  anus  and  perinseum  similar  to  that  caused  by  hsemorrhoids, 
urgent  desire  to  go  to  stool,  or  a  disagreeable  and  sometimes  burning 
heat  in  the  peringeum  with  a  feeling  of  fulness  and  weight  in  the 
pelvis.  These  pains  sometimes  become  so  intense  that  the  patient, 
not  being  able  to  remain  sitting  in  the  ordinary  way,  will  rest  in 
Turkish  fashion,  or  throw  the  weight  on  the  heels  placed  below  the 
opposite  tuberosities,  or  finally  lie  down  to  escape  this  discomfort. 
Sometimes  the  sitting  position  makes  the  patient  feel  as  if  a  hard  body 
pressed  on  the  anus  or  perinseum ;  at  other  times  it  is  as  if  such  a  hard 
body  pressed  painfully  upwards  on  the  uterus  and  abdominal  viscera. 
This  sensation  may  be  felt  under  various  circumstances,  especially  in 
pelvic  peritonitis ;  but  I  have  often  seen  it  when  the  uterus  alone  was 
affected ;  it  is  rarely  absent  with  hypertrophy  of  the  cervix,  especially 
when  this  coincides  with  fungous  granulations  or  metritis.     In  such 


PEESUMPTIVE    SIGXS    INDICATING  UTERINE    DISEASE       109 

cases  the  sufferer  not  only  avoids  sitting  long,  but  takes  great  care 
not  to  sit  down  abruptly^  knowing  that  by  so  doing  she  would  produce 
the  pain  I  have  just  described,  which  may  be  so  severe  as  sometimes 
to  induce  syncope. 

Standing  seems  to  cause  pain  which  neither  the  position  nor  the 
special  disease  can  always  account  for.  In  cases  of  displacement,  it  is 
natural  that  standing,  like  walking,  should  cause  a  troublesome  drag- 
ging on  the  ligaments  or  painful  pressure  of  the  displaced  or  pro- 
lapsed uterus  on  neighbouring  organs;  but  in  other  cases,  such  as 
leucorrhcea,  one  cannot  connect  cause  and  effect.  Whenever  the 
uterus  or  the  ovaries  are  affected,  they  necessarily  become  more  sen- 
sitive, and  they  are  sure  to  suffer  simply  from  the  weight  of  the 
abdominal  viscera.  It  may  be  in  this  way  that  standing  causes  pain. 
In  walking  the  weight  of  the  viscera  probably  comes  now  on  one  and 
now  on  another  part  of  the  pelvis ;  while  in  standing  the  suffering 
uterus  bears  the  whole  pressure  continuously,  and  consequently  many 
women  prefer  walking  to  standing. 

However,  in  the  majority  of  chronic  uterine  diseases,  walking  and 
other  physical  exercises  cause  the  most  violent  pain.  It  is  needless 
to  add  that  in  cases  where  pain  is  felt  when  the  patient  is  at  rest,  it 
becomes  much  more  severe  when  she  walks  or  otherwise  exerts  herself. 
Walking  so  generally  causes  pain  that  many  women  suffering  from 
uterine  disease  lose  the  habit  of  walking.  Others  can  walk  in  the 
house  or  on  a  smooth  flat  path,  but  suffer  as  soon  as  they  try  to  walk 
on  a  rough  road,  or  feel  the  vibration  caused  by  a  false  step  or  even 
by  going  down  stairs.  This  is  especially  so  in  cases  of  metritis  and 
perimetritis,  when  the  slightest  shake  is  felt  painfully  and  causes  the 
patient  instinctively  to  put  her  hand  on  the  hypogastrium.  It  is  easy 
to  understand  how  much  more  certainly  pain  will  be  produced  by 
other  and  more  violent  exercises,  such  as  dancing,  riding,  driving,  &c. 
I  have  seen  patients  suffer  terribly  after  a  little  waltzing,  and  have 
known  others  obliged  to  give  up  riding  because  it  excited  pain. 
Travelling  by  railway,  though  better  borne  as  a  rule  than  driving, 
sometimes  causes  great  discomfort,  the  continual  vibration  producing 
mental  as  well  as  physical  excitement  and  uneasiness. 

With  other  patients  uterine  pain  is  provoked  by  movements  of  the 
arms,  as  in  sewing  or  playing  the  piano ;  these  actions  often  caus- 
ing a  painful  reaction  in  the  hypogastric  region  and  throughout  the 
body.  ^^yjx 

Coitus  produces  pain  in  many  women  by  a  complex  process.  The  ^f*^ — 
physical  movement,  shock,  orgasm,  all  unite  in  bringing  about  the 
result.  We  must  ascertain  whether  pain  is  produced  by  intromission, 
depending  on  vaginitis,  fissure,  spasm,  or  contraction  of  the  vulva ;  or 
by  the  shock  against  the  uterus  causing  a  direct  effect  upon  this  organ 
and  the  surrounding  tissues.  Sometimes,  though  no  pain  is  felt  at 
the  moment,  great  general  fatigue,  as  well  as  throughout  the  pelvis, 
is  experienced  the  following  day.  As  a  rule  these  invalids  avoid 
sexual  intercourse,  either  on  account  of  the  suffering  it  entails  or 
because  of  real  uterine  inertia.     But  besides  causing  pain  intercourse 


110  GENERAL    SURVEY   OF   UTERINE  DISEASES 

may  become  very  diflBcult  and  in  some  cases  impossible.  Barnes  ^ 
considers  this  symptom  of  difficulty  so  important  that  he  has  given  it 
the  name  of  dyspareunia,  a  word  by  which  household  troubles  were 
often  signified  by  the  Greeks.  Dyspareunia  may  depend  on  (1)  vagi- 
nismus, i.e  spasm^  either  direct  or  reflex^  of  the  constrictors  of  the 
vulva  and  vagina;  (2)  pain;  (3)  chronic  nervous  irritability  due  to  a 
first  coitus  having  been  incomplete  or  awkwardly  performed ;  (4)  pain 
caused  by  inflammation ;  (5)  embarrassment;  (6)  tumours;  or  (7) 
malformations,  imperfect  development,  imperforate  hymen,  narrowness 
of  vagina,  &c.,  in  short,  whatever  the  cause  may  be  the  symptom  is 
one  that  necessitates  a  direct  examination. 

Tight  dresses  even  v^hen  worn  for  a  short  time  only  have  their 
influence  in  causing  pain.  Cruveilhier  long  ago  pointed  out  the 
effects  produced  by  tight  lacing  on  the  form  and  position  of  the  abdo- 
minal viscera ;  and  we  can  easily  understand  how  the  compression  of 
these  organs  and  their  pressure  on  the  diseased  uterus  or  ovaries  may 
cause  intolerable  suffering.  An  abdominal  belt  on  the  contrary  raises 
and  supports  the  viscera.  Indeed,  stays  are  often  voluntarily  relin- 
quished before  consulting  a  doctor. 

We  must  next  ascertain  whether  pain  can  be  elicited  artificially. 
This  is  necessary  with  all  patients  in  order  to  determine  the  seat  and 
exact  starting  point  of  the  pain ;  but  it  is  specially  important  with 
those  who,  from  special  idiosyncracy  or  from  a  hard  and  laborious 
life,  are  not  sensitive  to  pain.  The  simplest  plan  is  to  ask  the  patient 
to  make  the  movements  likely  to  cause  suffering.  A  woman  who  is 
seated  in  an  easy  chair  may  assure  us  in  good  faith  that  she  has  no 
pain  whatever ;  but  ask  her  to  rise  and  walk  across  the  room,  or  lift  a 
piece  of  furniture,  and  she  will  be  conscious  of  suffering  immediately. 
As  a  rule,  it  is  by  manual  examination  that  we  learn  the  seat  and 
degree  of  pain.  Abdominal  pressure,  digital  examination  by  the 
vagina  and  rectum,  separately  or  all  combined,  will  generally  elicit 
dull  latent  pain.  Abdominal  pressure  may  be  made  when  the  woman 
is  either  standing  or  lying,  if  standing  she  ought  to  lean  forward,  if 
lying  the  knees  ought  to  be  well  drawn  up,  so  as  to  relax  the  abdo- 
minal muscles ;  a  gentle  but  continued  pressure  must  be  made  with 
the  tips  of  the  fingers  over  the  hypogastric  and  iliac  regions  as  well  as 
in  the  groins.  If  pain  is  elicited  by  pressure,  we  ought  to  verify  our 
diagnosis  while  the  patient  is  standing,  by  placing  the  hand  trans- 
versely on  the  hypogastrium  above  the  pubis,  lifting  all  the  abdominal 
viscera  towards  the  diaphragm  and  letting  them  fall  abruptly ;  repeat- 
ing this  manoeuvre  two  or  three  times.  If  the  patient  feels  relieved 
when  the  viscera  are  lifted  up  and  experiences  pain  when  they  fall, 
we  are  able  to  determine  the  existence,  seat,  and  often  the  cause  of  the 
pain,  and  can  also  estimate  the  utility  of  a  hypogastric  belt  to  support 
the  abdomen. 

During  vaginal  and  rectal  examination  the  tip  of  the  finger  may 
press  on  the  neck  or  body  of  the  uterus,  or  on  the  ovary ;  or,  again, 
on  a  peri- uterine  tumour,  to  determine  whether  it  is  solid,  sanguineous, 
^  Diseases  of  Women,  2nd  edition,     London,  1878,  p.  65. 


PRESUMPTIVE    SIGNS    INDICATING    UTERINE    DISEASE       111 

or  purulent.  If  this  pressure  does  not  cause  suffering,  a  slight  shock, 
as  in  practising  balottement  to  diagnose  pregnancy,  may  elicit  pain. 
At  other  times  abdominal  palpation  must  be  associated  with  vaginal  or 
rectal  touch  before  we  can  determine  the  exact  seat  of  suffering,  which  is 
sometimes  in  the  ovary,  sometimes  in  the  uterus,  and  sometimes  in  a 
retro-uterine  tumour.  In  any  case  it  is  very  important  to  elicit  pain. 
When  felt  it  is  impossible  for  the  patient  to  conceal  her  disease  or  to 
ignore  its  existence.  It  is,  however,  necessary  to  point  out  an  error 
into  which  we  may  fall.  Some  patients,  especially  young  girls  who 
are  unaccustomed  to  the  contact  of  a  foreign  body  in  the  vagina,  partly 
from  sensitiveness,  shrink  with  alarm  and  fear  from  the  slightest  touch, 
sometimes  crying  out  as  if  in  pain.  If  this  occurs  just  as  the  finger 
touches  the  uterus  the  physician  is  all  the  more  likely  to  be  led  astray ; 
he  must  remember  that,  apart  from  the  sensitiveness  of  the  patient, 
this  apparent  manifestation  of  pain  may  be  owing  to  the  shock  or  (so 
to  speak)  to  the  surprise  of  the  organ ;  if  he  continues  the  examination 
gently  and  patiently  he  will  generally  succeed  in  discovering  the  real 
seat  of  pain. 

There  are  six  seats  of  pain — three  principal  and  three  accessory. 
The  three  principal  seats  are — 1,  the  iliac  regions ;  2,  the  loins  ;  and 
3,  the  hypogastrium. 

I.  Iliac  pain  is  the  most  common;  it  corresponds  to  the  iliac  fossa, 
spreading  towards  the  hypogastric  and  lumbar  regions,  but  especially 
towards  the  pelvic  brim  and  cavity.  This  pain  must  not  be  confounded 
with  true  lumbar  pain,  nor  with  intercostal  neuralgia,  which  patients  so 
often  complain  of  below  the  breast.  The  mistake  is  the  more  easily  made, 
as  both  kinds  of  pain  are  generally  felt  in  the  left  side.  Iliac  pain  is 
described  by  patients  as  pain  in  the  side ;  as  a  rule  this  is  a  pathogno- 
monic symptom  of  uterine  disease.  Aran  thinks  it  is  generally  due  to 
inflammation  of  the  ovary  or  appendages.  Many  cases  may  be  ex- 
plained in  this  way,  but  not  all,  because  ovaritis  is  not  limited  to  the 
left  side.  I  think  it  can  be  accounted  for  in  another  way;  just  as  pain  «~ 
in  the  back  may  arise  from  tension  of  the  utero-lumbar  ligaments,  so  \  Vv-- 
may  left  iliac  pain  be  produced  by  tension  of  the  broad  ligament.  This  ] 
may  occur  without  metritis,  ovaritis,  or  perimetritis.  The  uterus,  in 
some  morbid  conditions,  increases  in  size  and  weight ;  its  normal  in- 
clination to  the  right  being  still  more  exaggerated,  it  necessarily  drags 
on  the  left  side  of  the  broad  ligament ;  this  dragging  is  enough  to 
cause  pain,  and  may  even  produce  perimetritis. 

%.  Lumbar  pain,  generally  called  *^  backache,^'  though  less  frequent 
than  iliac  pain,  is  yet  very  common,  and  often  very  troublesome.  Some- 
times it  is  confined  to  the  renal  region,  or  it  may  spread  to  the  sacrum, 
or  even  to  the  abdomen ;  at  other  times  it  extends  from  the  loins, 
where  it  reaches  its  maximum,  down  each  side  to  the  iliac  regions  and 
even  to  the  hypogastrium  and  pubis,  encircling  the  abdomen  with  a 
belt  of  pain  and  sometimes  terminating  in  a  violent  uterine  spasm. 
Its  cause  is  as  variable  as  its  mode  of  manifestation.  Sometimes  it 
depends  on  the  contraction  of  the  utero-sacral  ligaments,  or  possibly  on 
their  distension,  from  the  descent  or  retroversion  of  the  uterus ;  some- 


112      GENERAL  SURVEY  OP  UTERINE  DISEASES 

times  on  congestion  distending  the  ovarian  veins  and  pampiniform 
plexus  J  or,  again,  it  may  be  due  to  the  accumulation  of  leucorrhoeal 
mucus  and  to  the  contractions  provoked  in  the  uterus  in  order  to  expel 
it ;  sometimes  it  is  caused  by  cervicitis,  whether  simple,  granular,  or 
ulcerative.  Lumbar  pain  generally  indicates  disease  of  the  cervix, 
whilst  iliac  pain  (especially  if  associated  with  dyspepsia)  is  more  fre- 
quently connected  with  an  affection  of  the  body  of  the  womb  or  of  one 
of  the  uterine  appendages.  Sacral,  like  anal  pain,  is  suggestive  of 
retro-flexion,  or  of  a  retro-uterine  tumour. 

3.  Hypogastric  pain  has  its  seat  immediately  above  the  pubis,  and 
seems,  more  than  any  other,  to  have  its  starting-point  in  the  body  of 
the  uterus  and  to  be  dependent  on  an  inflammation  of  that  organ.  It 
appears  when  artificially  elicited  rather  than  spontaneously.  Many 
patients,  also,  who  do  not  complain  of  it  at  first,  feel  it  as  soon  as 
pressure  is  applied  to  the  abdomen.  This  symptom  is  never  absent  in 
uterine  disease.  Although  this  pain  is  seldom  spontaneous,  it  is  still 
very  disagreeable  to  women ;  it  interferes  with  their  walking,  or,  if  they 
do  walk,  they  feel  the  necessity  of  supporting  the  hypogastrium  with  a 
belt,  or  they  keep  their  hands  in  front,  ready  to  protect  themselves 
from  the  slightest  shock  which  might  occur.  This  pain  must  not  be 
confounded  with  the  sensation  of  dragging  at  the  umbilicus  (associated 
with  sacral  pain),  which  is  often  a  symptom  of  retroflexion. 

The  three  accessory  seats  of  pain  are — 1,  the  anus  or  perinseum; 

2,  the  vagina  or  cervix  ;  3,  the  cavity  of  the  pelvis. 

1.  Anal  or  perhieal  pain  is,  generally  produced  by  pressure  from  a 
peri-uterine  tumour,  from  the  fundus  of  the  retroflected  uterus,  or 
from  the  uterus  itself,  either  hypertrophied  or  prolapsed.  I  have 
already  referred  to  patients  affected  with  hypertrophy  of  the  cervix, 
v^ho  suffered  pain  at  the  anus  and  perinseum,  not  only  in  walking  and 
riding,  but  when  sitting.  2.  Vaginal  pain  is  less  frequent.  In  cer- 
tain acute  diseases  the  uterine  pain  extends  to  the  vagina,  but  it  is 
more  often  due  to  the  development  of  peri-uterine  disease,  especially  if 
such  disease  is  of  an  acute  or  inflammatory  nature.  In  this  way  hema- 
tocele, retro-uterine  peritonitis,  peri-uterine  inflammation,  or  abscess, 
sometimes  produce  in  the  vagina  heat,  swelling,  or  sharp  throbbing 
pain  extending  to  the  vulva,  which  may  become  excruciating.  In 
chronic  disease  this  pain  is  often  not  felt  unless  artificially  elicited. 

3.  Pelvic  pain  is  usually  the  symptom  of  peri-uterine  disease,  or  of 
cystic  or  solid  tumours  of  the  ovary  or  uterus.  In  acute  peri-uterine 
diseases  such  pain  may  be  violent  and  accompanied  with  throbbing 
and  a  sensation  of  distension ;  in  chronic  diseases  it  is  dull  and 
heavy. 

Eadiating  pain  is  chiefly  pelvic.  Iliac  pain  extends  to  the  groins, 
either  along  the  round  ligament  or  by  the  ilio-pubic  branch  of  the 
lumbar  plexus.  In  this  case  the  radiation  assumes  a  neuralgic  cha- 
racter j  there  is  an  iliac  centre,  an  abdominal  centre,  and  one  in  the 
labia  majora.  Lumbar  pain  radiates  oftenest  along  the  course  of 
the  sciatic  nerve.  This  radiation,  like  neuralgic  pain,  is  occasional  and 
intermittent ;  but  it  may  be  more  frequent,  prolonged,  and  even  con- 


PRESUMPTIVE    SIGNS   INDICATING  UTERINE    DISEASE        113 

tinuous,  if  dependent  on  direct  compression  of  one  of  the  sciatic  nerves 
by  a  uterine^  ovarian^  or  pelvic  tumour.  The  hypogastric  pain,  like 
the  iliac,  sometimes  extends  to  the  groin,  but  oftener  to  the  upper  part 
of  the  thigh,  following  the  divisions  of  the  obturator  nerve,  or  extend- 
ing along  the  anterior  aspect  to  the  knee,  and  sometimes  below  it,  fol- 
lowing the  branches  of  the  crural  nerve.  The  other  pains,  whether 
sympathetic  or  reflex,  are  not  simple  radiations ;  they  have  already 
been  referred  to  under  the  head  of  general  disorders  of  the  nervous 
system. 

Pain  may  be  of  a  continuous  or  an  intermittent  type.  Continuous 
pain  varies  in  intensity  according  to  the  individual  and  to  the  disease. 
It  is  worthy  of  remark  that  the  most  painful  diseases  are  not  always 
the  most  serious,  and  that  certain  incurable  diseases,  such  as  cancer 
and  epithelioma  of  the  cervix,  may  be  developed  without  producing 
symptoms  fitted  to  arouse  the  anxiety  of  patients.  Hence  the  phy- 
sician is  almost  always  consulted  too  late  to  be  able  to  do  more  than 
palliate  suffering;  whereas  if  called  at  the  commencement  he  could 
have  removed  the  diseased  portion  of  the  neck  by  the  knife  or  cautery 
and  so  frequently  might  have  saved  life.  Cancer  itself,  whether  of  the 
neck  or  of  the  body,  does  not  cause  suffering  until  ulceration  begins  ; 
on  the  other  hand,  acute  inflammation,  neuralgia  and  catarrh  often 
produce  most  violent  pain.  The  intensity  of  pain  is  not  always  pro- 
portioned to  its  acuteness.  There  are  kinds  of  pain  which  are  intense 
but  dull,  giving  the  sensation  of  a  weight,  a  distension,  a  numbness  in 
the  various  regions  I  have  described,  and  especially  in  the  pelvis  and 
along  the  pelvic  nerves.  There  are  others  of  a  burning  or  lancinating 
character,  resembling  neuralgia,  but  less  persistent,  ajjpearing  and  dis- 
appearing in  proportion  to  the  pressure  exercised  by  the  uterus  on  the 
ramifications  of  the  crural,  obturator,  or  sciatic  nerves,  this  pressure 
depending  on  the  posture  adopted  by  the  patient. 

Intermittence  of  pain  depends  on  three  principal  causes  : — Inter- 
mittence  is  often  characteristic  of  neuralgic  pain.  The  neuralgia 
■which  accompanies  uterine  disease  may,  like  other  neuralgia,  cease 
after  a  certain  time,  or  even  acquire  the  character  of  periodicity.  The 
sudden  attacks  and  exacerbations  which  are  often  observed  in  chronic 
uterine  diseases,  especially  in  those  of  an  inflammatory  nature  involv- 
ing the  peritoneum  and  accompanied  by  suppuration,  may  also  explain 
the  occurrence  of  intermittence.  Such  crises  are  often  dependent 
on  disorders  of  menstruation,  and  each  monthly  period  may  be  the 
signal  for  an  exacerbation  of  the  disease  and  of  pain.  Or  intermittence 
may  depend  on  tlie  very  nature  of  the  affection,  and  on  the  uterine 
contractions  which  are  developed  in  the  course  of  the  disease.  These 
contractions  are  painful.  They  are  easily  distinguished  by  the  expul- 
sive character  they  assume;  ))atients  complain  of  a  sensation  of  some- 
thing pushing  downward,  as  in  labour  pains ;  young  girls  even  can 
trace  the  coimeclion,  when  their  attention  has  been  called  to  the  coin- 
cidence, between  tliese  pains  and  the  expulsion  of  a  certain  quantity  of 
mucus  or  clots  of  blood.  They  are  caused  by  an  accumulation  of 
mucus  or  muco-pus  in  cases  of  catarrh  and  leucorrhoca ;  by  an  accu- 

8 


114  GENERAL    SURVEY    OP    UTERINE    DISEASES 

iDulation  of  blood  in  hsemorrhages ;  or  they  may  be  due  to  stenosis  of 
the  09,  or  to  polypi  or  tumours  in  the  uterine  cavity,  which  may 
produce  local  irritability  and  spasm. 

Another  indication  is  afforded  by  the  character  of  the  dis- 
charges from  the  vulva ;  whether  sanguineous,  mucous  or  muco- 
purulent. 

1.  Uterine  hcBmorrhage  is  by  no  means  an  invariable  symptom  of 
disease  of  the  womb.  In  some  cases  there  is  little  or  no  derangement 
of  the  menstrual  function  ;  but  this  is  the  exception.  The  recurrence 
of  the  monthly  period  may  be  tardy,  or  too  frequent,  or  there  may  be 
intermenstrual  haemorrhage;  oftenest  of  all  ther'e  is  dysmenorrhoea 
with  diminution  in  the  quantity  of  blood.  If  the  catamenia  have 
never  appeared,  we  must  learn  whether  general  and  local  symptoms 
recurring  periodically  may  not  have  indicated  the  menstrual  molimen ; 
or  there  may  even  have  been  haemorrhage  within  the  uterus  without 
any  external  discharge,  the  blood  being  retained  from  imperforate 
hymen,  obliteration  or  deviation  of  the  cavity  of  the  cervix,  or  an 
occlusion  of  the  uterine  orifice.  It  is  important  to  distinguish  the 
cases  in  which  there  is  retention  from  those  in  which  the  haemorrhage 
has  never  taken  place,  and  from  those  still  rarer  instances  in  which 
the  uterus  is  wanting.  I  have  seen  an  instance  of  the  last  kind,  and 
also  several  cases  where  the  uterus  had  no  external  outlet  owing  to 
the  cicatricial  obliteration  of  the  vagina  following  upon  gangrene  after 
delivery.  I  have  operated  on  several  girls  for  imperforation  of  the 
cervix  and  have  found  menstruation  subsequently  take  place  regu- 
larly, and  I  have  often  seen  menstruation  entirely  or  partially 
obstructed  by  stenosis  of  the  os  externum  or  internum,  or  by  ano- 
malies in  the  position  of  the  orifice  or  in  the  direction  of  the  cervical 
canal.  Fortunately,  amenorrboea  is  much  oftener  due  to  some  func- 
tional disturbance  or  to  a  morbid  condition  of  the  general  health, 
such  as  chlorosis  or  anaemia,  and  it  must  not  be  forgotten  that 
amenorrhosa  may  possibly  depend  on  pregnancy  even  in  a  woman  who 
has  never  menstruated. 

The  next  point  is  to  ascertain  whether  the  menstrual  function  is  nor- 
mally performed.  In  a  number  of  uterine  diseases  the  catamenia  are 
excessive,  in  others  defective.  It  is  important  to  ascertain  whether 
the  quantity  of  blood  habitually  lost  has  increased  or  diminished. 
Differences  are  relative  rather  than  absolute ;  for  one  woman  normally 
loses  very  little  in  comparison  of  another.  The  length  of  the  period 
also  varies,  and  in  this  respect  we  must  take  individual  idiosyncracies 
into  account.  Some  women  may  be  in  good  health  although  the 
menses  only  last  for  a  few  hours,  whilst  in  other  cases  they  continue 
for  twelve  or  fifteen  days.  The  normal  period  of  recurrence  is  also 
variable  though  in  most  cases  the  menses  return  every  twenty-eight 
days ;  in  some  women,  however,  the  ordinary  term  is  thirty,  thirty-five, 
or  even  forty  days,  whilst  in  other  cases  it  is  reduced  to  twenty-five, 
twenty,  or  even  fifteen  days.  We  must  carefully  distinguish  men- 
struation from  simple  haemorrhage  having  no  connection  with  the 
catamenia.     Although  uterine  hasmorrhage  may  sometimes  be  accom- 


PEESUMPTIVE   SIGNS    INDICATING  UTEEINE    DISEASE        115 

panied  by  general  and  local  symptoms  which  make  a  differential 
diagnosis  difficult,  yet  the  menstrual  flow  is  generally  marked  by 
distinctive  signs  not  confined  to  the  uterus  but  involving  the  whole 
generative  system,  and  accompanied  by  an  unusual  sensibility  in  the 
woman  as  well  as  other  symptoms,  varying  in  different  individuals,  but 
habitually  characteristic  of  each ;  the  whole  being  sufficient  to  prevent 
our  confusing  the  physiological  function  with  the  pathological  pheno- 
menon, in  spite  of  their  single  common  element,  the  loss  of  blood. 
The  general  and  local  symptoms  of  the  menstrual  molimen  are  so 
marked  that  they  can  easily  be  diagnosed  even  when  there  is  no 
haemorrhage.  Sometimes  we  see  the  catamenial  molimen  occurring  in 
the  intermenstrual  period,  accompanied  by  pain,  local  fatigue  and 
reaction  on  the  general  system,  which  is  all  the  more  intense  because 
not  followed  by  a  critical  haemorrhage  that  would  give  relief  (see 
Chapter  on  Menstruation).  It  is  no  less  important  to  have  correct 
information  as  to  the  quality  and  colour  of  the  blood  discharged. 
Sometimes  it  is  darker,  sometimes  paler,  than  normal.  It  may  be  so 
dark  as  to  be  almost  black,  with  dense  viscous  consistence,  or  perhaps 
in  a  state  of  coagulation,  being  expelled  probably  at  intervals  rather 
than  continuously.  All  this  indicates  that  the  blood  is  of  venous 
rather  than  arterial  origin,  or  that  it  is  mixed  with  mucous  secretions, 
or  that  it  has  been  long  retained  in  the  uterine  cavity  owing  to  inertia 
or  to  constriction  of  the  orifice.  At  other  times  the  discharge  is  pale 
and  thin,  of  serous  or  sero-sanguinolent  nature,  leaving  on  the  linen  a 
pale  pink  stain  surrounded  by  a  grey  areola ;  this  is  symptomatic  of 
chlorosis,  uterine  catarrh,  &c.  The  blood  may  be  fluid  or  may  be 
expelled  partly  in  clots.  The  size  of  these  clots  and  the  presence  or 
absence  of  pain  at  the  moment  of  their  expulsion  may  indicate 
increased  size  of  the  cavity  of  the  womb  with  inertia  of  its  walls,  or 
on  the  other  hand,  contraction  with  spasm  and  partial  occlusion  of  the 
orifices.  In  short,  menstruation  may  undergo  many  important 
changes.  "When  these  derangements  are  marked  they  are  designated 
by  the  names  of  amenorrhoea,  dysmenorrhoea,  menorrhagia  and  me- 
trorrhagia; these  may  be  not  only  important  symptoms  in  diagnosing 
a  case,  but  essential  morbid  conditions  which  will  be  described  as  such 
in  due  time. 

It  must  always  be  borne  in  mind  that  these  different  symptoms  may 
not  only  indicate  uterine  disease,  but  possibly  pregnancy,  abortion,  de- 
livery, &c.  While  no  one  doubts  the  significance  of  amenorrhoea  and 
haemorrhage,  dysmenorrhoea  is  treated  as  of  less  moment,  in  consequence 
of  a  common  id^a  that  many  women  suffer  at  their  monthly  periods 
who  yet  have  nothing  the  matter  with  them  ;  but  this  is  a  mistake  ;  the 
more  experience  we  gain  the  more  we  are  convinced  that  dysinenorrhffia, 
especially  when  associated  with  dyspareunia  and  sterility,  is  invariably 
symptomatic  of  a  mechanical  obstacle  to  the  excretion  of  the  catamenia. 
We  must  learn  all  we  can  as  to  the  history  of  these  haemorrhages,  the 
frequency  of  their  recurrence,  whether  they  are  spontaneous  or  elicited, 
if  they  occur  in  the  morning  or  evening,  whilst  the  patient  is  at  rest 
or  after  exposure  to  fatigue,  as  in  walking,  driving,  riding,  and  espe- 


116  GENERAL    SURVEY   OF    UTERINE   DISEASES 

cially  in  coitus.  A  few  drops  of  blood  after  congress,  especially  if 
associated  with  muco-purulent  leucorrhoeaj  ought  to  make  us  suspect 
fungous  granulations  of  the  cervix,  if  not  a  more  serious  organic  lesion, 
sometimes  cancer. 

2.  Jjeucorrlma,  or  the  various  discharges  from  vulva,  vagina,  or 
uterus,  ought  to  engage  our  attention  for  two  reasons — 1.  Because 
many  patients  do  not  mention  this  symptom  to  their  doctor,  thinking 
that  all  women  suffer  in  this  way.  2.  As  leucorrhoea  is  always  abnormal 
its  existence  convinces  us  that  a  pathological  change  of  some  kind  has 
taken  place  in  the  generative  system.  We  must  find  out  if  these  dis- 
charges are  spontaneous,  or  if  they  are  caused  by  walking,  coitus,  &c.  ; 
if  they  are  insignificant  or  abundant,  continuous  or  intermittent ;  if 
they  cause  inconvenience  and  are  accompanied  by  fatigue,  pain  in  the 
stomach,  dragging  in  the  loins  and  in  the  middle  of  the  back.  The 
peculiar  characteristics  of  these  discharges  give  us  indications,  and 
often  point  out  to  us  with  certainty  their  source  and  even  the  nature 
of  the  disease  which  produces  them. 

The  normal  secretions  of  the  vulva,  vagina  and  uterus  are  not  con- 
tinuous but  intermittent,  only  taking  place  simultaneously  with  the 
performance  of  their  principal  functions — coitus,  menstruation,  preg- 
nancy and  delivery.  They  may  also  occur  normally  after  any  fatigue 
or  excitement,  whether  local  or  general.  When  pathological,  these 
discharges  may  retain  their  normal  character,  being  produced  simply 
by  hypersecretion,  or  they  may  assume  an  abnormal  nature,  depending 
on  some  derangement  of  the  secretion. 

Simple  liypersecfetion. — The  vulval  mucus  is  transparent  and  viscid, 
with  acid  smell  and  reaction,  presenting  nucleated  epithelium  with 
fragments  of  pavement  epithelium,  the  secretion  being  either  continuous 
or  intermittent,  as  the  case  may  be.  The  vaginal  mucus  is  a  milky- 
white  emulsion,  not  viscid,  with  acid  reaction,  continuous  secretion, 
and  a  large  preponderance  of  solid  elements,  giant  cells  of  pavement 
epithelium  predominating  over  the  liquid  elements.  The  uterine 
mucus  is  an  albuminous  liquid,  very  viscid  and  stringy,  sometimes 
tenacious,  closely  resembling  white  of  egg,  often  quite  transparent, 
secreted  intermittently,  with  alkaline  reaction,  containing  cylindrical 
or  ciliated  epithelium  with  mucous  globules  or  nucleated  epithelial 
cells;  the  cervical  secretion  the  most  tenacious  of  all,  and  contain- 
ing more  ciliated  epithelium  than  the  mucus  of  the  fundus.  As  to 
age,  we  must  remember  that  vulval  leucorrhcea  is  specially  common 
in  children,  vaginal  leucorrhoea  more  frequent  in  young  women, 
uterine  leucorrhoea,  especially  when  cervical,  njost  common  in 
middle-aged  and  old  women.  The  first  is  sebaceous  (except  the 
hypersecretion  of  the  vulval  glands  of  Bartholini) ;  the  second,  epi- 
thelial (common  or  pavement)  ;  the  third,  mucous  or  nucleated. 

Derangement  of  secretion. — The  vulval  discharge  may  become  yellow, 
green,  purulent,  or,  in  mixing  with  hypersecretion  of  sebaceous  matter, 
may  form  a  magma,  with  strong,  acid,  cheesy  smell,  very  irritating  to 
the  adjoining  parts,  which  become  excoriated.  The  vaginal  secretion 
may  become  very  thick,  curdy,  greasy  (never  viscid  nor  gluey),  always 


PRESUMPTIVE    SIGNS  INDICATING  UTERINE   DISEASE         ]  1  7 

acidj  or,  on  the  contrary,  very  abundant,  more  fluid,  mixed  with  pus, 
yellow  or  green  or  sero-purulent,  like  the  pathological  secretion  pro- 
duced by  a  bhster  excreted  continuously,  very  irritating,  and  causing 
excoriation  of  the  vulva  and  upper  part  of  the  inner  side  of  the  thighs. 
It  is  an  undoubted  fact  that  the  vagina  suppurates  much  more  frequently 
than  the  uterus,  which  is  in  accordance  with  Virchow's  remark  that 
mucous  membrane  with  cylindrical  epithelium  is  slow  to  suppurate. 
The  uterine  excretion  may  become  white,  grey,  yellow,  even  green,  or 
streaked  with  yellow  and  white,  of  yellowish-green  colour,  partly 
transparent,  always  alkaline,  more  fluid,  sometimes  quite  serous,  but 
often  tenacious,  excreted  intermittently  and  with  the  knowledge  of 
the  patient  who  experiences  uterine  colics  as  soon  as  the  contractions 
of  the  organ  expel  the  liquid,  which  is  sometimes  accumulated  in  large 
quantity  in  the  uterine  cavity  and  then  falls  into  the  vagina  or  on  the 
vulva  in  one  mass,  as  the  white  of  egg  would  do.  When  the  cervix  is 
affected  the  mucus  may  become  so  gluey  and  tenacious  that  it  adheres 
to  the  organ  for  a  loag  time,  and  is  only  detached  from  it  in  a  half 
solid  form,  similar  to  the  cervical  plug  of  pregnancy.  To  these  cha- 
racteristics, of  which  intelligent  patients  are  well  aware,  we  may  add 
those  furnished  to  us  by  stains  on  the  linen,  of  which  I  shall  speak 
when  giving  the  diagnosis  of  leucorrhoea. 

Mixture  with  another  liquid,  normal  or  pathological. — The  dis- 
charges may  become  serous  or  sanguineous,  which  is  almost  always 
the  indication  of  a  serious  derangement  of  the  secretion,  of  superflcial 
ulceration  with  exudation,  or  of  the  existence  of  an  ulcer,  granulations 
or  fibroma,  or  of  some  organic  lesion.  They  may  become  sero-purulent, 
purulent,  ichorous,  with  fetid  smell,  the  latter  too  often  the  indication 
of  a  cancerous  affection.  I  have  never  been  mistaken  as  to  that  smell, 
to  which  sufficient  attention  is  not  paid.  When  the  utero-vaginal 
secretion  has  accumulated  owing  to  the  presence  of  a  pessary,  and  is 
heated,  it  has  a  foul  smell  certainly,  but  only  that  of  acid  fermentation 
or  heated  pus,  which  all  surgeons  notice  on  laying  bare  a  wound  when 
an  abundant  suppuration  has  been  retained  by  the  lint  dressing ;  the 
smell  of  suppurating  cancer,  on  the  contrary,  is  nauseous,  stale  rather 
than  ackl,  somewhat  similar  to  macerated  animal  matter,  often  noticed 
at  a  distance,  or  as  soon  as  the  dress  of  the  patient  is  removed.  At 
other  times  the  discharges  assume  a  character  of  liquid  transparency, 
and  are  called  watery  discharges,  hydrorrhcea,  hydrometria  (See  this 
word).  They  may  have  different  sources,  as  we  shall  see  when  we 
come  to  consider  leucorrhoea.  These  watery  excretions  are  sometimes 
of  no  moment;  at  other  times  they  are  symptomatic  of  serious  dis- 
eases, such  as  an  ovarian  cyst,  epithelioma,  &c.  The  variety  of  patho- 
logical fluids  is  great.  There  are  others  to  which  I  have  not  yet  re- 
ferred, because  there  is  much  about  them  of  which  we  are  still  ignorant. 
I  mean  those  fluids  produced  by  gaseous  excretions  or  physometna 
(See  this  word).  We  must  beware  of  the  rather  frequent  accident  of 
the  introduction  of  air  by  the  syringe  into  the  vagina  or  uterus,  or  of 
the  facility  with  which  the  vagina  opens  and  sucks  in  atmospheric  air 
during  pronation  in  some  women  after  delivery,  or  of  the  less  common 


118  GENERAL    SURVEY   OF    UTERINE    DISEASES 

accident  of  a  recto-vaginal  fistula,  wliich,  though  too  small  to  admit 
the  passage  of  the  fseces,  allows  intestinal  gases  to  pass ;  but,  apart 
from  these  accidents,  gas  may  be  developed  in  the  vaginal  cavity  and 
even  in  the  uterus  so  as  to  distend  it.  This  symptom,  called  physo- 
metria,  may  be  caused  by  putrid  decomposition  of  fragments  of  foetus 
or  placenta,  or  by  decomposition  of  uterine  secretions  when  abundant 
and  retained  by  some  cause  in  the  womb. 

Lastly,  discharges  may  produce  a  sensation  of  joain,  which  though  not 
common  is  very  intense  when  present.  I  have  already  spoken  of  ex- 
coriations on  the  labia  and  thighs;  but  in  addition  to  this,  there  is 
often,  especially  in  women  who  have  ])assed  the  menopause,  an  intoler- 
able vulval  pruritis.  This  pruritis  is  often  coincident  with  a  vaginal 
excretion,  and  may  be  due  to  want  of  cleanliness  or  to  a  disease  of  an 
inflammatory,  syphilitic,  pruriginous,  or  herpetic  nature.  In  such 
cases  the  vagina  is  almost  always  painful,  covered  by  an  erythematous 
eruption,  and  sometimes  excoriated.  The  pruritus,  however,  often 
exists  alone  as  the  effect  of  a  peculiar  nervous  erethism  depending 
directly  or  indirectly  on  the  uterine  disease,  especially  when  not 
accompanied  by  any  eruption,  and  when  it  does  not  yield  to  a  solution 
of  bicarbonate  of  soda  or  to  local  applications  of  tar  or  tannic  acid. 


Certain  Signs  Furnished  by  Direct  Examination 

By  the  time  we  have  reached  this  stage  we  have  often  more  than 
the  presumption,  we  have  almost  the  certainty,  sometimes  we  have 
the  complete  certainty  that  the  patient  before  us  is  affected  by  uterine 
disease.  We  can  easily  lead  her  to  share  this  certainty  and  to  see  the 
necessity  for  a  direct  examination.  Methodic  interrogation  has 
enabled  us  to  diagnose  uterine  disease ;  a  direct  examination  will 
enable  us  to  make  a  differential  diagnosis.  The  means  of  investiga- 
tion at  our  disposal  are,  palpation,  the  touch,  the  speculum,  the 
sound. 

1.  Abdominal  Falpation — This  is  the  simplest  means  of  investi- 
gation at  our  command  and  therefore  the  one  we  ought  to .  employ 
first.  It  is  a  kind  of  modified  touch  exercised  by  the  whole  hand,  or 
part  of  it,  through  the  abdominal  walls.  The  form  of  the  abdomen 
should  be  noticed,  and  the  patient  should  be  made  to  change  her 
position  so  that  we  may  ascertain  if  there  is  fluctuation.  The  other 
means  of  external  examination  are  percussion,  auscultation,  the  ex- 
ploratory puncture,  mensuration,  &c. 

Palpation. — Palpation  should  be  practised  in  two  ways;  when  the 
patient  is  standing  and  when  lying.  It  matters  little  whether  we 
begin  with  the  one  or  the  other.  If  the  patient  goes  to  the  consult- 
ing room  of  her  doctor,  it  is  natural  to  begin  with  vertical  palpation ; 
if  on  the  contrary  she  is  obliged  to  keep  her  bed  and  sends  for  the 
doctor  he  begins  with  horizontal  palpation.  In  whatever  order  we 
take  them,  the  combination  of  these  two  modes  of  palpation  in  two 
different  positions,  is  more  important    than   would  appear   at   first 


SIGNS    FURNISHED    BY    DIRECT    EXAMINATION  119 

sight ;  each  position  helps  us  to  discover  certain  symptoms  which  we 
could  not  otherwise  have  made  out. 

The  patient  being  in  the  erect  posture,  her  back  supported  by  a 
piece  of  furniture  or  by  the  left  hand  of  the  physician,  the  right  hand 
is  placed  over  the  epigastric  or  umbilical  region  ;  when  exploring 
these  regions  with  the  palm  of  the  hand  their  temperature  should  be 
observed.  Gradually  and  methodically  the  hand  is  brought  down, 
going  from  right  to  left,  any  change  in  the  form  and  size  of  the 
abdomen  being  noted  which  may  be  dependent  on  a  tumour  con- 
nected with  the  uterus  or  ovaries,  or  on  an  increase  in  the  size  of  the 
womb  or  its  appendages,  or  to  a  fluid  or  semi-fluid  effusion  in  the 
peritoneum  or  pelvis,  or  merely  to  distension  from  a  tympanitic  con- 
dition of  the  bowels,  very  common  in  uterine  disease.  Above  all, 
the  size  and  sensitiveness  of  the  various  parts  of  the  hypogastrium 
and  pelvic  cavity  should  be  ascertained ;  and  to  do  this,  we  must 
ask  the  patient  to  lean  forward,  so  as  to  relax  the  abdominal  muscles. 
In  depressing  the  teguments  with  the  tips  of  the  fingers  we  often 
elicit  sharp  pain  immediately  above  the  pubis,  or  on  the  inner  side 
of  the  left  iliac  fossa,  at  the  transverse  diameter  of  the  brim. 
These  pains,  together  with  tumefaction  of  this  region,  leave  little 
doubt  as  to  the  existence  of  an  inflammatory  disease  of  the  uterus  or 
ovary.  Any  increase  in  the  temperature  of  the  hypogastrium  ought 
to  be  ascertained  at  the  beginning  of  the  examination  as  this  is  an 
additional  sign  in  favour  of  the  supposition  of  chronic  inflamma- 
tion of  the  uterus,  its  appendages  or  surrounding  tissues.  We 
should  also  take  advantage  of  the  upright  position  of  the  patient  to 
obtain  another  indication  which  is  too  often  neglected,  although  valu- 
able to  the  physician  both  as  regards  diagnosis  and  treatment.  Instead 
of  pressing  down  the  abdominal  parietes  towards  the  pelvis  as  at  first, 
"we  raise  the  mass  of  viscera,  so  as  to  drive  them  upwards  and  backwards 
towards  the  diaphragm ;  then  we  let  them  fall  down  abruptly.  By 
repeating  this  little  manoeuvre  two  or  three  times  we  ascertain 
whether  the  pressure  exercised  on  the  uterus  by  the  weight  of  the 
viscera  is  a  cause  of  pain,  and  consequently  we  can  determine  whether 
an  abdominal  belt,  preserving  the  uterus  from  this  painful  pressure 
will  be  helpful  to  the  patient.  When  on  the  couch  the  patient  should 
be  on  her  back,  the  legs  bent  on  the  thighs,  the  thighs  on  the  pelvis 
and  slightly  apart,  the  head  raised  by  a  pillow  so  as  to  relax  the 
abdominal  muscles.  Whilst  making  the  examination  it  is  well  to 
speak  to  the  patient  so  as  to  distract  her  attention,  for  many  women, 
from  modesty  or  from  sensitiveness,  contract  their  muscles  so  firmly 
when  touched,  that  it  is  impossible  to  proceed.  When  the  patient  is 
lying,  we  are  able  to  depress  the  abdominal  walls  much  more  than 
when  standing,  and  so  can  better  ascertain  the  more  deeply-seated 
changes  ;  not  only  those  due  to  uterine  tumours,  fibromata,  ovarian 
cysts  and  pelvic  tumours,  but  those  also  which  have  their  rise  in 
disorders  of  other  organs,  such  as  the  kidneys,  the  ureters,  the 
bladder,  the  small  intestine,  the  crccum  and  the  ascending  colon. 
In  this   way  it  is  possible  to    distinguish  a   mass    of   stercoraceous 


120  GENEEAL   SUEVEY    OP  UTEEINE   DISEASES 

matter  in  the  sigmoid  flexure,  which  has  sometimes  caused  so  much 
pain  as  to  have  led  to  errors  of  diagnosis.  In  this  investigation  of 
abdominal  and  pelvic  tumours  by  palpation  it  is  not  sufficient  to 
ascertain  the  difterences  in  size,  form,  sensibility,  and  position  of  the 
different  organs ;  we  must  also  learn  to  distinguish  differences  in  con- 
sistency and  in  resistance  to  pressure  presented  by  these  viscera  or  by 
tumours.  A  single  finger  will  sometimes  appreciate  these  differences 
better  than  the  whole  hand.  In  this  way  may  be  ascertained  the 
transmission  of  arterial  pulsation,  vascular  or  respiratory  vibrations, 
intestinal  gurgling,  the  depressibility  and  molecular  mobility  of  the 
contents  of  some  tumours  susceptible  of  displacement,  the  stony, 
cartilaginous  or  fibrous  hardness  of  others,  the  softness  of  a  certain 
number,  the  resistance  of  abscesses  or  cysts,  &c.  I  do  not  mean 
to  say  that  palpation  alone  will  enable  us  to  diagnose  small  mobile 
tumours,  or  even  to  elicit  pain  in  inflamed  organs,  which  recede 
from  pressure  as  the  uterus  does  when  not  too  large  and  not 
retained  by  adhesions.  But  associated  with  vaginal  touch  palpa- 
tion is  one  of  the  most  certain  and  most  valuable  means  of 
diagnosis.  When  practised  on  the  hypogastric  and  lateral  regions 
of  the  abdomen  by  pressing  the  pelvic  organs  down,  it  brings  them 
nearer  to  the  exploring  finger  and  sometimes  indeed  enables  the 
examiner  to  hold  them  between  the  finger  introduced  into  the  vagina 
or  rectum,  and  the  hand  which  depresses  the  abdominal  parietes. 
The  fundus,  the  Fallopian  tubes,  the  ovaries,  mobile  pelvic  tumours, 
the  posterior  side  of  the  uterus,  would  escape  investigation  if  vaginal 
and  rectal  touch  were  not  complemented  by  abdominal  palpation  and 
even  exceptionally  by  another  mode  of  examination  to  which  I  shall 
afterwards  refer  under  the  name  of  rectal  palpation. 

One  last  remark :  before  abdominal  palpation  is  practised  the 
bowels  should  be  evacuated  by  an  enema  or  laxative,  and  the  bladder 
naturally  or  by  catheter,  otherwise  it  will  not  give  us  the  certain 
information  that  we  require. 

The  complementary  means  of  external  examination  are :  percussion, 
quest  for  fluctuation,  change  of  posture,  auscultation,  observation  as 
to  the  appearance  and  shape  of  the  abdomen,  an  exploratory  puncture, 
and  mensuration.     These  are  practised  when  the  patient  is  lying. 

Peraissio7i  of  the  different  regions  of  the  abdomen,  and  especially 
in  those  parts  where  there  is  abnormal  tumefaction,  enables  us  to  detect 
the  presence  of  foreign  bodies,  whether  gaseous,  solid  or  liquid,  and  to 
determine  the  exact  limits  of  a  tumour  of  the  uterus  or  ovary  (left 
undecided  by  palpation),  to  discover  their  inequalities,  and  recognise 
other  complications,  &c.^ 

'  E.g.  percussion  enables  us  to  perceive  tympanitic  resonance  of  the  intestine 
at  the  highest  part  of  the  abdomen  near  the  umbilicus,  or  on  the  contrary  at  its 
most  dependent  parts  the  flanks,  an  essential  distinction  in  diagnosing  between 
ascites  and  an  encysted  tumour ;  it  limits  the  bounds  of  a  solid  or  fluctuating 
tumour  ;  it  enables  us  to  ascertain  the  presence  of  dulness  in  the  most  depen- 
dent parts  (ascites),  or  above  the  pubis,  uniformly  in  the  centre,  with  fluctua- 
tion, (vesical  tumour,  retention  of  urine),  or  in  the  In'pogastrium  sloping 
downwards  with  irregular  surface,  &c.  (pregnancy,  hypertrophy  of  the  uterus, 


SIGNS    FUENISHED    BY    DIRECT    EXAMINATION  121 

Examining  for  fluctuation  is  not  less  important  in  some  cases ;  it 
enables  us  to  discover  efl'usions  which  may  be  in  the  lower  part  of  the 
peritoneal  cavity  and  helps  us  to  diagnose  an  ovarian  cystj  and  to  ascer- 
tain whether  it  is  simple  or  multilocular,  partly  liquid  and  solid, 
whether  complicated  with  ascites,  &c.  The  association  of  percussion 
and  even  auscultation  with  this  mode  of  examination  leads  us  to  dis- 
cover the  characteristic  hydatid  thrill,  and  so  distinguish  an  acephalo- 
cystic  tumour  of  the  pelvis  or  omentum  from  any  other  kind  of  tumour. 
In  certain  cases  palpation  must  be  associated  with  digital  examination 
in  order  to  discover  fluctuation,  the  finger  of  one  hand  resting  on  the 
most  dependent  part  of  the  vaginal  tumour,  while  the  other  hand  de- 
presses the  hypogastrium  firmly.  Short  taps  on  this  region  made  by 
a  finger  of  the  same  hand  are  transmitted  by  the  liquid  to  the  tip  of 
the  finger  within  the  vagina. 

Changes  of  posture  and  shocks  given  to  the  abdomen  are  useful 
after  percussion  and  palpation  in  giving  additional  information. 
In  order  to  discover  dulness,  resonance,  fluctuation  and  the  various 
sounds  which  are  recognised  by  auscultation  we  must  examine  the 
patient,  not  only  when  she  is  standing  and  lying,  but  also  on  the 
back  on  each  side  in  pronation,  and  even  on  elbows  and  knees,  as 
Bozeman  does  for  the  operation  of  vesico-vaginal  fistula.  Nothing  is 
so  useful  as  these  changes  of  posture  in  displacing  peritoneal 
effusions  and  solid  tumours  attached  to  the  broad  ligaments  or  to  the 
mesentery,  or  in  changing  the  relationships  of  organs  or  abnormal 
products. 

When  these  changes  of  posture  are  not  sufficient  to  enlighten  us 
as  to  the  weight  and  consistency  of  organs  and  as  to  the  presence  of 
solids,  liquids  and  gases  in  the  abdomen,  we  may  be  able  to  throw 
light  on  the  diagnosis  by  concussion,  which  communicates  a  balotte- 
meiit,  more  or  less  considerable,  to  all  the  abdominal  viscera.  This 
balottement,  as  well  as  changes  of  posture,  may  help  us  greatly  in 
diagnosing  the  case,  not  only  because  of  the  impressions  transmitted 
directly  to  the  physician,  but  because  of  the  new  sensations  which  it 
causes  to  the  patient. 

Auscultation  is  especially  useful  when  we  have  to  distinguish  between 
pregnancy  and  a  uterine  or  ovarian  tumour.  When  the  uterus  contains  a 
living  foetus  we  can  generally  hear  the  foetal  heart  as  well  as  the  uterine 
souffle.  The  existence  of  the  heart  sounds  in  an  abdominal  tumour, 
more  or  less  lateral  and  not  dependent  on  the  uterus,  which  is  rela- 
tively defective  in  development,  ought  to  lead  us  to  diagnose  extra- 
uterine pregnancy.  This  question  should  always  be  determined  before 
forming  a  diagnosis  of  an  abdominal  tumour.  In  auscultating  cases 
of  ovarian  tumours  or  of  uterine  fibromata  compressing  the  aorta  or  the 
iliac  arteries,  a  souffle  can  almost  always  be  perceived  on  one  side  analo- 

fibi'oraa,  &c.),  or  on  one  side  of  the  pelvis  extending  to  a  more  or  less  elevated 
part  of  the  iliac  fossa  (tuiiionrs  of  the  broad  ligaments  or  ovaries),  or  at  the 
most  elevated  part  of  the  abdomen,  with  or  without  Hnctuation  and  with 
tympanitic  resonance  in  the  ilanks  (cysts,  cystosarcomata,  solid  tumours  of  the 
ovary). 


122  GENERAL    SURVEY    OP   UTERINE    DISEASES 

gous  to  what  is  called  the  uterine  souffle.  This  sound  is  often 
perceived  on  the  surface  of  the  tumour  and  evidently  arises  from 
the  great  vessels  which  traverse  it,  whether  it  be  due  to  an  ovarian 
cyst  or  to  the  distension  of  the  uterus  by  an  enormous  fibroma ; 
it  depends  probably  on  the  compression  which  the  volume  of  the 
tumour  exercises  on  these  vascular  trunks  at  some  point,  and  is  an 
indication  of  their  great  size.  Auscultation  also  enables  us  to  dis- 
tinguish intestinal  gurgling,  tympanitic  resonance,  peritoneal  friction 
sounds,  &c. 

The  external  appearance  of  the  abdomen  gives  the  physician  an 
opportunity  of  receiving  impressions  which  palpation  alone  would  not 
have  afforded.  We  not  only  note  the  changes  in  colour  and  appear- 
ance of  the  abdomen,  the  umbilical  depression,  the  pigmentation  of  the 
linea  alba,  presumptive  signs  of  a  commencing  pregnancy,  the  vibices 
due  to  the  distension  of  the  belly  by  a  previous  pregnancy,  ascites,  or 
a  tumour,  wrinkles,  cicatrices,  marks  of  chafing,  &c.,  but  it  enables 
us  also  to  detect  the  slightest  change  in  the  form  of  the  abdomen. 
The  patient  ought  alternately  to  be  standing  and  lying,  especially  lying 
on  the  back.  In  this  position  we  can  easily  distinguish  the  general 
swelling  due  to  meteorism ;  the  peculiar  tumefaction  of  the  sigmoid 
flexure,  colon  or  csecum,  due  to  constipation ;  the  vesical  tumour 
caused  by  retention  of  urine;  the  uterine  tumour  of  pregnancy;  the 
more  limited  protuberance  of  a  solid  tumour,  of  the  womb,  ovary,  or 
broad  ligaments ;  the  prominent  tumour,  raising  the  umbilicus  and 
even  the  xiphoid  cartilage,  caused  by  the  enormous  distension  of  an 
ovarian  cyst ;  the  iliac  or  hypogastric  puffiness  accompanying  peri- 
metritis ;  lastly,  the  increased  size  of  the  belly  in  the  flanks  and  in 
the  iliac  regions  due  to  ascites. 

The  exploratory  puncture  is  of  the  same  utility  in  diagnosing  tumours 
of  the  genital  organs  as  of  other  parts  of  the  body.  It  determines  the 
consistency  and  nature  of  the  contents  of  the  tumour  by  the  issue  of  a 
drop  of  liquid  or  of  a  solid  particle.  It  may  be  applied  not  only  to  the 
abdomen  and  to  the  external  organs  of  generation,  but  also  to  the 
vagina,  to  the  posterior  vagino-uterine  cul-de-sac,  to  the  uterus,  or  to 
tumours  of  its  cavity. 

As  the  complement  of  palpation,  tapping  is  even  more  useful  than 
an  exploratory  puncture.  Evacuation  of  the  tumour  helps  us  in  the 
same  way  that  evacuation  of  the  bowels  and  bladder  does.  I  do  not 
say  that  this  is  necessary  in  order  to  diagnose  the  existence  of  an 
ovarian  tumour,  but  it  is  impossible  to  ascertain  the  peculiarities  of 
its  form  and  composition,  the  complications  and  adhesions,  unless  the 
evacuation  of  the  cyst  permits  the  examination  of  the  empty  sac  and 
its  appendages  by  means  of  palpation  (associated  with  touch),  the 
abdominal  parietes  being  now  as  easily  depressed  as  they  were  distended 
i^ormerly. 

Mensuration  frequently  repeated  is  useful  in  determining  the 
changes  of  size.  We  must  measure  the  circumference  of  the  abdomen 
carefully  with  a  tape,  and  always  from  the  same  points,  using  the 
precaution  of  taking  measurements  from  several  points,  in  difl'erent 


SIGNS    FURNISHED    BY    DIEECT    EXAMINATION  123 

directions   (horizontally   and  vertically),   before    and    after  practising 
the  exploratory  puncture. 

2.  Digital  touch. — All  practitioners  agree  in  giving  to  digital  touch 
the  first  place  as  a  means  of  examination  ;  it  is  all  the  more  valuable  as 
being  the  one  which  causes  least  distress  to  the  patient,  owing  to  our 
being  able  to  employ  it  without  uncovering  her.  I  insist  on  the  capital 
importance  of  digital  examination  for  two  reasons.  The  first  is  because  it 
has  been  neglected  since  the  discovery  of  the  speculum.  Now,  I  have 
seen  so  many  women  affected  by  serious  uterine  or  peri-uterine  disease 
which  their  physicians,  nevertheless,  had  failed  to  discover,  because  they 
had  only  examined  them  with  the  speculum,  that  I  cannot  too  strongly 
warn  practitioners  of  the  danger  of  abandoning  touch  for  the  spe- 
culum, which  can  do  no  more  than  correct  and  complete  the  informa- 
tion given  by  the  touch.  The  second  is  my  hope  of  persuading 
young  practitioners  to  practise  this  mode  of  examination.  Now,  in 
order  to  be  able  to  do  so,  or  indeed  to  make  any  other  examination 
profitably,  it  is  not  only  dexterity  that  is  required,  we  must  also  have 
an  exact  knowledge  of  the  sensations  due  to  a  normal  and  an 
abnormal  condition  of  the  organs  explored  -,  this  knowledge  is  only 
acquired  by  habit,  and  I  can  assure  all  young  practitioners  who  wish 
to  perfect  themselves  in  this  mode  of  investigation,  that  they  will  be 
surprised  to  observe  what  constant  progress  they  make.  Digital 
touch,  hke  abdominal  palpation,  is  practised  when  the  patient  is 
standing  or  lying ;  in  England  the  usual  position  is  on  the  left  side. 
In  most  cases  it  is  indispensable  to  examine  the  patient  by  touch 
when  she  is  standing.  It  is  often  the  only  means  of  reaching  the 
cervix  in  girls,  as  with  them  the  uterus  is  generally  very  high  up. 
It  is  the  same  with  tall  women  who  are  stout,  because  the  cellular 
adipose  tissue,  which  lines  the  perineum,  shortens  the  examining 
finger  ;  the  vertical  position  is  sometimes  insufficient  to  enable  us  to 
reach  the  cervix,  unless  the  patient  makes  an  expulsive  efi'ort  which 
forces  the  uterus  downwards.  The  vertical  position  facilitates  exami- 
nation of  the  cervix  of  a  pregnant  woman,  as  well  as  that  of  a  uterus 
containing  a  fibroid  tumour ;  in  both  of  which  cases  the  womb  rises 
above  the  pelvis  as  Simpson  has  pointed  out.  This  mode  of  exami- 
nation also  helps  us  to  practise  balottement  and  to  appreciate  the 
weight  of  an  inflamed  or  hypertrophied  uterus  which  may  be  an 
important  element  of  diagnosis.  Lastly,  this  alone  can  give  exact 
information  as  to  elevation,  descent,  displacements  or  flexions  of 
the  womb  ;  for  all  these  displacements  are  modified  by  the  horizontal 
position.  When  making  the  vaginal  examination  in  the  erect  posture 
the  patient  ought  to  have  her  back  against  a  piece  of  furniture,  the 
legs  slightly  apart,  the  body  leaning  forward  so  as  to  relax  the 
abdominal  muscles,  the  hands  on  the  back  of  a  chair.  The  physician 
on  a  low  seat,  or  on  his  knees,  introduces  the  right  hand  under  the 
dress  of  his  ])atient,  having  previously  anointed  the  index  finger,  so  as 
to  preserve  it  from  infection,  as  well  as  to  facilitate  its  introduction. 
He  follows  the  line  of  the  right  thigh  and  tries  to  reach  the  posterior 
commissure  of  the  labia,  endeavouring  to  avoid  the  anus  behind  and 


124 


GENERAL    SURVEY    OF    UTERINE    DISEASES 


the  clitoris  in  front  in  order  to  save  the  patient  the  annoyance  of 
having  these  sensitive  organs  touched.  Contrary  to  the  advice  given 
by  some  authors  the  other  fingers  ought  not  to  be  bent  on  the  palm 
of  the  handj  as  doing  so  shortens  the  index  finger  nearly  an  inch. 
They  ought  on  the  contrary  to  be  left  in  extension  and  as  far  as 
possible  from  the  index,  the  thumb  directed  forwards  towards  the  top 
of  the  vulva,  on  one  side  of  the  clitoris,  resting  on  the  labium,  whilst 
the  three  other  fingers,  directed  backwards,  should  rest  on  the 
perineum  and  anus,  raising  them  if  necessary,  so  as  to  shorten  the 
vagina  and  bring  the  uterus  nearer  the  index  finger.  We  must  learn 
to  execute  this  little  manoeuvre  in  spite  of  the  resistance  offered  by  the 
coccyx  and  adipose  tissue  of  the  perineum ;  for  in  certain  cases 
we  could  not  otherwise  reach  the  uterus,  its  appendages,  or  peri- 
uterine tumours  situated  high  up  in  the  pelvis.  When  the  index 
reaches  the  posterior  commissure  of  the  labia  it  depresses  the  four- 
chette  and  insinuates  itself  easily  into  the  vagina.  The  finger  is 
made  to  feel  its  way  all  along  the  posterior  wall  of  the  vagina  towards 
the  cervix,  taking  note  of  the  condition  of  the  mucous  membrane,  its 
temperature,  observing  whether  it  is  dry  or  moist,  whether  its  surface 
is  smooth  or  rough,  &c.  Having  reached  the  cervix,  it  first  examines 
the  two  lips  and  the  os  and  then  carefully  examines  the  fundus  of  the 


Fig  111. — Vaginal  toucb  associated  with  aMominal  palpation. 

vagina.     Then  it  makes  its  way  back  to  the  vulva,  now  exploring  tlie 
anterior  wall  of  the  vagina  in  the  same  way  as  the  posterior  was  pre- 


SIGNS    FURNISHED    BY  DIEECT  EXAMINATION  125 

viously  examined.  Sometimes^  in  place  of  one  finger  we  may  have  to 
introduce  two  or  even  four  when  we  have  to  ascertain  the  presence, 
form  and  consistency  of  a  tumour,  its  connections  with  the  uterus, 
whether  pediculated,  &c.  The  vagina  should  next  be  explored  whilst 
the  patient  lies  on  her  back ;  only  by  this  means  are  we  able  to 
ascertain  certain  pathological  conditions,  the  existence  and  limitation 
of  ovarian  or  peri-uterine  tumours,  the  distinction  between  these 
tumours  and  the  uterus  itself  when  deviated  or  flexed.  Vaginal 
touch  associated  with  palpation  may  give  to  our  diagnosis  a  certainty 
which  could  not  be  acquired  by  any  other  means.  It  is  the  best  of 
all  modes  of  examination  for  enabKng  us  to  judge  as  to  the  integrity 
of  the  uterus,  the  ovaries  and  the  Fallopian  tubes.  Having  asked  the 
patient  to  flex  the  lower  limbs  and  open  them  slightly,  the  physician, 
without  uncovering  her,  proceeds  to  practise  the  touch  with  the  same 
precautions  as  he  employed  in  the  vertical  position.  I  think  it  is 
better  for  him  to  pass  the  hand  under  the  thigh  nearest  him ;  it  is 
more  convenient,  there  is  less  risk  of  touching  the  clitoris,  it  allows 
the  finger  to  penetrate  further,  and  above  all  forces  the  patient  to  keep 
her  thighs  well  flexed,  which  facilitates  the  examination.  After 
having  acquired  experience  in  this  mode  of  examination,  in  using  the 
other  hand  simultaneously  for  palpation  and  in  depressing  the  various 
parts  of  the  hypogastrium,  there  are  very  few  lesions  which  can  escape 
our  investigation. 

In  England  it  is  usual  for  the  patient  to  be  placed  on  the  left  side 
when  examined.  It  is  also  the  custom  in  that  country  for  women  to 
be  delivered  in  this  position.  The  knees  are  drawn  up,  the  head  and 
shoulders  directed  obliquely  across  the  couch,  whilst  the  nates  are 
brought  near  the  edge  of  the  bed.  In  this  position  the  vulva  is  easily 
penetrated  without  uncovering  the  patient,  but  it  is  difficult  to  practise 
palpation,  or  to  appreciate  uterine  displacement  and  the  relative  situa- 
tion of  the  various  organs  as  exactly  as  in  the  dorsal  position ;  the 
only  advantage  of  the  lateral  decubitus  is  that  it  sometimes  reveals  to 
us  the  mobility  of  a  tumour  or  the  existence  of  adhesions  attaching  the 
uterus  and  its  appendages  to  the  pelvis.  Scanzoni  and  other  writers 
have  proposed  that  in  the  case  of  virgins  we  should  content  ourselves 
with  the  information  furnished  us  by  rectal  touch,  as  if  this  mode  of 
examination  were  not  far  more  repugnant  to  the  delicacy  of  girls  than 
the  vaginal  touch  itself.  We  can  persuade  a  young  girl  as  well  as  a 
married  woman  of  the  necessity  of  a  vaginal  examination,  and  it  is  easy 
to  practise  this  without  injuring  the  hymen — the  physical  sign  of  vir- 
ginity. The  precautions  to  be  taken  are  these  :  the  patient  should  be 
requested  to  bring  her  thighs  close  together  in  place  of  separating 
them,  as  this  puts  the  hymen  in  a  state  of  tension  unfavorable  to  the 
entrance  of  the  finger  into  the  vagina.  The  index  finger  (well 
greased)  should  then  be  placed  on  the  fourchette,  and  rest  there  for 
a  few  seconds,  till  the  spasm  caused  by  the  contact  of  a  foreign  body 
has  passed ;  then  let  it  glide  gently  forwards,  depressing  not  only  the 
fourchette,  as  in  the  case  of  a  married  woman,  but  also  the  inferior 
border  of  the  vulva  and  the  hymen  attached  to  it.     Bringing  the  thighs 


126  GENERAL    SURVEY    OF    UTERINE    DISEASES 

together  makes  this  membrane  depressible,  just  as  bringing  the  fingers 
together  malies  their  commissure  depressible.  It  is  only  after  having 
ascertained  the  depression  of  the  hymen  that  the  finger  should  be 
slowly  insinuated  into  the  vagina,  when  it  will  penetrate  without  paiu 
or  difficulty.  I  have  often  practised  the  vaginal  touch  under  these  cir- 
cumstances, and  have  never  caused  suffering  or  haemorrhage,  nor  torn 
the  hymen,  which  is  often  more  or  less  obliterated  in  these  young  girls 
owing  to  the  leucorrhoea  Vt^hich  so  often  accompanies  uterine  diseases 
in  virgins.  It  is  not  so  much  the  hymen  as  the  sphincter  of  the  vulva 
which  it  is  difficult  to  pass,  but  it  can  always  be  managed  by  going 
slowly  and  gently.  Fmally,  whatever  may  be  the  age  of  the  patient, 
the  condition  of  the  genital  organs,  or  the  position  in  which  we  prac- 
tise the  touch,  we  must  endeavour  to  make  the  examination  as  short  as 
possible,  remembering  that  it  is  always  disagreeable  and  often  painful. 
On  this  account  we  must,  above  all,  learn  to  practise  the  vaginal  touch 
methodically ;  we  must  know  beforehand  all  that  we  ought  to  seek 
for  and  all  that  we  can  find  by  its  assistance,  observing  every  indica- 
tion given  to  us  as  we  go  along.  Having  already  explained  how  it 
ought  to  be  practised,  I  will  now  point  out  the  valuable  information 
which  it  gives  to  the  physician  as  he  proceeds  from  the  vulva  to  the 
uterus,  and  from  the  uterus  to  the  vulva.  In  the  first  place  this  ex- 
amination may  disclose  to  us,  or  at  least  give  us  reason  to  suspect, 
some  malformation.  I  refer  the  reader  to  the  description  given  in 
another  place  of  these  abnormalities.  Next,  the  condition  of  the  labia 
and  the  orifice  of  the  vagina  should  be  observed,  the  contraction  which 
this  latter  and  the  vagina  itself  may  have  undergone  after  the  meno- 
pause being  sometimes  so  great  as  even  to  make  the  entrance  of  the 
finger  difficult.  The  presence  of  tumours,  cysts  of  the  labia,  of  the 
vulva,  of  Cowper's  gland,  of  the  posterior  vaginal  wall,  tumours  of  the 
rectum  perceptible  through  this  wall,  distension  of  the  bowels  due  to 
the  presence  of  faeces,  which  are  depressible,  and  which  nevertheless 
have  sometimes  been  taken  for  real  tumours,  may  be  determined  by  this 
mode  of  examination.  In  withdrawing  the  finger  we  ascertain  the 
state  of  the  mucous  membrane  and  the  existence  of  any  cysts,  polypi, 
or  vegetations  which  may  be  found  on  the  anterior  wall  of  the  vagina. 
Vesical  catarrh,  cystitis,  stone,  gravel,  may  be  recognised  by  the 
pain  caused  by  pressure  of  the  finger  on  the  anterior  wall ;  inflamma- 
tion of  the  urethra,  blenorrhagia,  vascular  or  fibro-yascular  tumours 
of  the  urethra  and  meatus  are  brought  to  light  by  compressing  the 
inferior  part  of  the  anterior  vaginal  wall  against  the  pubic  arch.  The 
finger,  before  reaching  the  cervix,  may  discover  in  the  vagina  a  tumour 
originating  in  the  uterus;  this  is  often  a  polypus,  a  fibrous  tumour, 
elongation  of  the  vaginal  portion  of  the  cervix  or  of  one  of  the  lips, 
rarely  retroversion  of  the  uterus.  It  is  important  to  discover  the  con- 
nection of  this  tumour  with  the  cervix  and  fundus.  At  other  times 
there  may  be  an  encysted  tumour  in  one  of  the  vaginal  walls,  or 
a  solid  tumour  in  the  portion  of  the  broad  ligament  which  runs' 
along  the  lateral  part  of  the  vagina,  and  which  may  be  an  inflammation 
of  the  lymphatics.     Having  reached  the  cervix  we  must  first  note  the 


SIGNS    FURNISHED    BY    DIEECT   EXAMINATION  127 

mobility  or  immobility  of  the  uterus,  distinguishing  the  mobility  of 
the  cervix  due  to  flabbiness  from  that  of  the  organ  as  a  whole.  When 
the  uterus  moves  freely  on  its  axis  the  finger  is  able  not  only  to  dis- 
place the  cervix,  but  in  so  doing  to  perceive  by  the  resistance  offered 
the  inclination  of  the  fundus  in  the  opposite  direction.  Mobility  is  an 
important  sign  of  the  integrity  of  the  uterus  and  surrounding  organs; 
it  IS  destroyed  by  adhesions  following  peri-uterine  inflammation  ;  it  is 
diminished  by  diseases  of  the  ovaries  and  Fallopian  tubes,  and  even  by 
uterine  disease,  or  by  the  tumefaction,  hypertrophy,  and  chronic  in- 
flammation of  the  organ.  Even  when  the  uterus  is  mobile  the  finger 
may  find  the  cervix  changed  in  position,  above,  below,  behind,  or  in 
front  of  the  normal  position.  When  the  cervix  is  placed  forwards  and 
high  up,  as  if  resting  on  the  pubis,  there  is  reason  to  suspect  the  ex- 
istence of  a  tumour  forcing  it  in  that  direction.  At  other  times  the 
direction  of  the  cervix  is  changed.  It  may  be  inclined  forwards  owing 
to  retroversion,  but  this  is  rare.  More  frequently  it  is  directed  back- 
wards, the  consequence  either  of  an  anteversion  or  of  tumefaction  of 
the  anterior  lip.  In  order  to  discover  this  deviation  the  finger  must 
follow  the  posterior  wall  of  the  vagina  till  its  tip  can  pass  beiiind  the 
cervix.  In  this  case  the  anterior  lip  is  first  reached  and  can  be 
examined.  The  posterior  lip  may  have  become  inaccessible,  and  may 
only  be  discovered  after  much  seeking,  and  with  difficulty  be  forced 
into  the  axis  of  the  vagina  So  as  to  allow  the  finger  to  penetrate  into 
the  ])ostenor  cul-de-sac.  At  other  times,  though  less  often,  the  cervix 
is  inclined  to  the  right  or  left,  according  to  the  position  of  the  fundus. 
This  position  can  only  be  ascertained  by  a  careful  examination  as  to 
which  side  the  os  is  directed  ;  unless  this  is  done  we  should  be  apt 
to  be  deceived  by  the  difference  of  size  between  the  two  lips.  The 
form  of  the  cervix,  its  temperature,  its  hardness,  softness,  irregularity 
of  surface,  &c.,  ought  to  be  carefully  investigated  by  the  touch.  The 
neck  may  be  conical  in  place  of  being  round.  This  cone  may  hang 
freely  in  the  vagina,  may  even  be  hypertrophied  in  a  longitudinal  direc- 
tion, occupying  the  centre  of  the  canal,  or  may  be  compressed  against 
one  of  its  walls  whilst  preserving  its  mobility  like  the  rest  of  the 
uterus.  When  compressed  against  one  side  constantly  to  the  front  and 
to  the  left  the  finger  discovers  on  the  opposite  side,  i.  e.  behind  and  to 
the  right,  an  enormous  vaginal  cul-de-sac,  the  size  being  due  to  the 
penis  habitually  slipping  over  the  conical  cervix  and  lodging  there 
during  coitus.  This  state  of  things  is  sometimes  made  worse  by  the 
position  of  the  os  being  on  the  side  in  place  of  on  the  summit  of  the 
co)ie,  and  is  a  cause  of  sterility,  all  the  more  important  to  diagnose 
because  it  can  be  remedied  by  partial  amputation  of  the  cervix.  This 
abnormally  exaggerated  conical  cervix  must  not  be  confounded  with 
the  slightly  conical  one  often  found  in  virgins,  and  which  is  quite 
normal.  The  cervix  may,  on  the  contrary,  be  fiattened  like  a  mush- 
room, the  lips  turned  back,  forming  a  circular  border,  which  projects 
beyond  the  upper  part  of  the  neck.  There  may  also  be  a  ditl'erence  of 
size  between  the  two  lips  ;  the  posterior  one  is  generally  the  longer,  the 
anterior  the  thicker.     The  anterior  lip  often  becomes  hypertrophied 


128  GENEEAL   SUEVEY   OF   UTEEINE  DISEASES 

and  engorged ;  the  posterior  more  painful,  owing  to  granulations  or 
ulceration-  I  have  already  described  the  varieties  of  form  presented 
by  the  vaginal  portion  of  the  cervix  in  treating  of  congenital  anomalies. 
The  temperature  of  the  cervix  and  also  of  the  vagina  may  be  higher 
than  in  a  normal  state.  This  is  an  almost  certain  sign  of  metritis  or 
of  peri-uterine  inflammation.  The  consistency  is  variable  also.  Some- 
times the  cervix  is  hard  as  in  hypertrophy ;  when  there  are  follicular 
cysts  or  commencement  of  cancer  the  surface  is  irregular.  At  other  times 
it  is  soft,  being  easily  indented  by  the  finger.  If  this  softening  is 
accompanied  by  ascent  of  the  organ  and  balotteraent  it  may  be  only 
a  sign  of  pregnancy ;  but  if  coincident  with  increased  size,  high  tem- 
perature, disposition  to  haemorrhage,  &c.,  it  may  be  a  sign  of 
congestion,  inflammation,  catarrh,  or  of  fungous  growths. 

The  position,  form,  size,  penetrability  of  the  os,  are  all  important 
elements  in  the  diagnosis.  The  os  may  look  in  various  directions, 
owing  either  to  natural  causes  or  to  deviation  of  the  organ,  flexion  of 
the  cervix,  or  lastly,  to  a  difference  in  the  size  of  its  lips,  e.  g.  one  of 
them  may  be  so  much  swollen  or  hypertrophied  as  partly  to  cover  the 
other,  which  has  preserved  its  natural  size.  The  os  externum  is  most 
frequently  a  transverse  fissure ;  sometimes  it  is  a  more  or  less  circular 
orifice.  In  a  woman  who  has  had  children  the  fissure  is  more  marked, 
larger,  and  somewhat  gaping ;  in  the  angles  of  the  fissure  are  hard 
cicatricial  marks,  perceptible  to  the  touch.  Sometimes,  even  in 
virgins,  the  orifice  is  large  enough  to  admit  the  end  of  the  finger. 
Unless  there  is  pregnancy  this  indicates  an  abnormal  dilatation  due  to 
catarrh,  chronic  inflammation,  congestion,  or  the  presence  of  a 
polypus,  or  other  intra-uterine  tumour,  causing  contractions  in  the 
body  of  the  uterus,  which  tend  to  open  the  neck.  The  surface  of 
the  lips  often  present  sensible  irregularities.  Sometimes  we  find 
bleeding  granulations,  sometimes  nodules,  tubercles,  irregularities, 
point  to  the  development  of  little  tumours.  The  lips  may  also  be  the 
seat  of  ulcers  and  fungous  vegetations,  or  of  real  tumours,  vascular, 
follicular,  or  fibrous,  more  or  less  pediculated,  as  well  as  of  cancer. 
Through  the  gaping  neck  the  finger  may  enter  the  cervical  and  even 
the  uterine  cavity,  and  discover  a  clot  of  blood,  a  conception,  an  inter- 
stitial tumour,  sessile  or  pediculated,  polypi,  fungous  vegetations, 
cancers,  &c.  It  is  important  to  ascertain  whether,  if  the  touch  pro- 
duces pain,  in  what  way  and  at  what  points  it  is  elicited.  Sometimes 
pain  is  caused  by  a  movement  communicated  to  the  uterus,  by  an 
attempt,  successful  or  otherwise,  to  displace  it ;  it  then  indicates  a 
morbid  condition  of  the  appendages,  adhesions  between  the  uterus  and 
the  peritoneum,  the  ovaries  or  Fallopian  tubes.  Sometimes  it  is  caused 
by  pressure  of  the  finger  on  the  neck  or  body  of  the  uterus,  and  is 
then  dependent  on  increased  sensitiveness  of  this  organ;  it  is  felt  most 
when  recourse  is  had  to  bimanual  palpation.  This  sensitiveness  may 
be  confined  to  one  limited  point  in  the  organ.  It  indicates  general  or 
partial  metritis,  or  irritation  symptomatic  of  commencing  organic 
lesion.  It  occurs  most  frequently  in  the  posterior  lip,  wliich  seems 
more  disposed  to  inflammation  and  ulceration  than  the  anterior  one. 


SIGNS    FURNISHED    BY    DIRECT    EXAMINATION  129 

wliich^  on  the  other  hand,  has  a  tendency  to  tumefaction  and  hyper- 
trophy. At  the  same  time  it  is  easy  to  recognise  whether  the  size  of 
the  organ  has  increased,  not  only  the  size  of  the  neck,  but  that  of  the 
body.  Tumefaction  sometimes  attacks  both  parts  of  the  womb  at  once  ; 
at  other  times  only  the  body  is  affected,  the  neck  seeming  to  be  normal, 
but  above  it  can  be  felt,  through  the  vaginal  cul-de-sac,  a  rounded 
tumour,  very  similar  to  the  form  of  the  uterus  in  the  beginning  of 
pregnancy.  The  regularity  of  outline,  the  elastic  and  moderately  firm 
consistency  of  the  tumour,  as  well  as  its  mobility,  should  help  us  to 
distinguish  it  from  a  fibrous  tumour,  a  flexion,  an  ovarian  tumour,  a 
heematocele,  or  from  a  peri-uterine  inflammation.  The  immobility  of 
the  uterus  greatly  facilitates  this  differential  diagnosis.  Whether  the 
uterus  be  flexed  or  not,  it  loses  its  mobility  if  it  contracts  adhesions 
with  neighbouring  organs,  either  in  front  or  behind ;  but  even  though 
no  adhesions  are  formed,  if  there  be  peri-uterine  inflammation,  inflam- 
matory tumefaction  of  the  uterus  or  surrounding  tissues,  there  will  be 
a  relative  immobility  owing  to  the  severe  pain  which  any  movement 
produces.  If  the  inflammation  has  produced  an  effusion  into  one  of 
the  peritoneal  cul-de-sacs  or  in  the  broad  ligaments,  the  uterus  is  not 
only  rendered  immobile,  it  is  displaced.  Sanguineous  effusions  pro- 
duce the  same  results ;  retro-uterine  hsematocele,  for  example,  displaces 
the  uterus,  forces  it  forwards  and  upwards  behind  the  pubis,  whilst  the 
tumour  projects  into  the  posterior  vaginal  cul-de-sac.  In  this  case  the 
womb  is  as  immovable  as  if  fixed  in  the  centre  of  a  mass  of  plaster 
which  had  hardened  around  it. 

In  conclusion,  the  careful  examination  of  the  vagina  all  round  the 
cervix  furnishes  us  with  the  most  valuable  information.  In  a  normal 
state  the  cul-de-sac  is  smooth  and  easily  depressed  by  the  finger  in 
either  direction,  the  uterus  rising  when  this  is  done  ;  but  it  may  un- 
dergo various  changes.  I  have  often  found  it  as  if  glued  to  the  pelvis, 
as  the  result  of  adhesions  caused  by  peri-uterine  inflammation;  at  other 
times  it  is  diminished  in  size  by  peri-uterine  inflammation,  a  hsemato- 
cele, or  by  some  other  tumour  situated  behind,  before,  or  on  one  side 
of  the  cervix.  Sanguineous  effusions  and  peri- uterine  inflammatory 
tumefactions  do  not  always  project  into  the  vagina,  but  they  always  pre- 
vent our  being  able  to  depress  it  indefinitely ;  they  offer  a  more  or  less 
determined  resistance  to  pressure  in  lieu  of  the  sensation  of  empty 
space  due  to  the  displacement  of  mobile  organs.  At  other  times  they 
form  a  more  or  less  prominent  border  all  round  the  cervix,  or  more 
especially  on  one  side  (corresponding  to  one  of  the  broad  ligaments), 
or  in  the  posterior  cul-de-sac  (corresponding  to  Douglas's  space).  The 
touch  may  also  disclose  to  us  in  this  cul-de-sac  behind,  and  either  to 
right  or  left  of  the  uterus,  the  presence  of  very  sensitive  globular 
tumours,  due  to  ovaritis  or  abscess  of  the  Fallopian  tube  ;  whilst  behind, 
and  more  especially  at  the  base  of  the  broad  ligaments,  we  may  also  find 
inflamed  and  indurated  glands  which  are  very  painful.  By  the  touch 
we  also  recognise  tumours  formed  by  the  uterus  itself  when  flexed.  We 
must  learn  not  to  confound  these  various  tumours.  Peri- uterine 
tumours  can    be  distinguished  from  ovaritis    by  rectal    touch,  and 

0 


130  GENERAL    SURVEY    OF    UTERINE    DISEASES 

flexions  from  other  tamours  by  the  sound-;  it  is  also  most  important  to 
be  able  to  appreciate  not  only  the  size  of  these  tumours,  but  also  the 
sensibility  of  the  peri-uterine  tissues.  Let  us  always  remember  that 
when  the  peritoneum^  the  peri-uterine  cellular  tissue  and  the  appendages 
are  in  a  normal  state,  the  examining  finger  should  find  the  surface 
everywhere  smooth  and  depressible. 

Having  completed  the  thorough  investigation  just  described,  we 
ought  to  observe  whether  the  finger  has  brought  away  any  blood  or 
mucus  (milky-white,  glairy,  or  purulent) ,  pus,  ichor,  cancerous  matter, 
&c.  Note  should  be  taken  of  any  hsemorrhage  which  may  accompany 
or  follow  the  examination  in  the  case  of  bleeding  fungosities,  cancer, 
epithelioma,  &c. 

Rectal  touch  cannot  supply  the  place  of  vaginal  touch  ;  it  is  as 
repugnant  to  the  modesty  of  women  and  it  gives  us  less  information. 
It  is  often  necessary  but  ought  only  to  be  employed  when  requisite  to 
complete  a  doubtful  diagnosis.  If  we  asked  our  patient^s  permission, 
we  should  expose  ourselves  to  an  almost  certain  refusal ;  therefore  it  is 
better  to  practise  it  immediately  after  the  vaginal  touch,  just  as  if  it 
were  usual  and  the  natural  complement  of  the  other  examination. 
Hence  it  follows  that  the  patient  should  be  in  the  same  position  as 
when  examined  j)er  vaginam,^  the  only  precaution  necessary  being  to 
have  advised  the  patient  to  take  an  enema  a  few  hours  previous  to  the 
examination.  After  having  passed  the  sphincters,  the  finger  having 
penetrated  about  two  inches,  comes  upon  a  resisting  and  rounded 
tumour  in  front,  which  is  the  neck  of  the  uterus  pressing  more  or  less 
on  the  anterior  wall  of  the  rectum  in  proportion  to  its  size,  its 
position,  and  its  deviation  towards  the  sacrum.  Above  the  protuber- 
ance of  the  cervix  the  index  discovers  the  body  of  the  womb,  and 
passes  over  its  posterior  surface  but  rarely  over  the  fundus,  unless  it 
be  inclined  towards  the  concavity  of  the  sacrum  owing  to  a  retrover- 
sion or  retroflexion.  On  depressing  the  abdomen  with  the  other 
hand  and  forcing  the  uterus  downwards,  i.e.  combining  palpation 
with  rectal  touch,  we  can  better  explore  the  posterior  surface,  the 
fundus,  the  outlines  of  the  womb  and  the  various  tumours  which  may 
be  found  behind  or  on  its  sides.  This  mode  of  examination  helps  us 
not  only  to  recognise  flexions,  deviations,  tumours  of  the  posterior  wall 
of  the  uterus,  such  as  fibroma,  phlegmons,  the  results  of  pelvi-perito- 
nitis,  inflammatory  or  cystic  tumours  of  the  ovaries  and  Fallopian 
tubes,  extra-uterine  pregnancies,  &c.,  but  it  also  allows  us  (especially 
when  associated  with  abdominal  palpation)  to  judge  as  to  the  size,  the 
consistency,  the  mobility,  the  sensibihty  of  these  difi'erent  tumours, 
and  to  obtain  a  precision  in  diagnosis  which  vaginal  touch  failed  to 
afford.  We  must  take  care  to  raise  the  perineum  as  much  as 
possible,  for  its  thickness  in  stout  women  makes  rectal  as  well  as 
vaginal  touch  more  difiicult.  Rectal  touch  is  the  only  means  we  have 
of  ascertaining  the  absence  of  the  uterus.  In  this  case  it  must  be 
combined  not  only  with  palpation  and  vaginal  touch  but  also  with 
catheterism  of  the  bladder.  In  short,  rectal  touch,  alone  or  asso- 
ciated with  vaginal  touch,  is  necessary  in  order  that  we  may  judge  of 


SIGNS    FURNISHED    BY    DIHECT    EXAMINATION 


131 


the  condition  of  the  recto-vaginal  septum,  its  tumours,  abscesses,  per- 
forations, fistulse,  &c.  Recamier  used  to  insist  on  the  necessity  of 
introducing  two  fingers  of  one  hand,  the  index  and  middle  finger,  one 
in  the  rectum  the  other  in  the  vagina ;  or  the  thumb  in  the  vagina 
the  index  in  the  rectum ;  or  the  index  of  one  hand  in  the  vagina  and 
that  of  the  other  in  the  rectum.  This  is  the  only  way  to  diagnose 
small  retro-uterine  tumours.  Touch  is  not  even  always  sufficient ;  we 
must  sometimes  inspect  the  mucous  membrane  of  the  posterior 
vaginal  wall,  forcing  it  through  the  vulva  by  a  kind  of  artificial  recto- 
cele,  or  we  may  have  to  examine  the  anterior  wall  of  the  rectum, 
pressing  it  down  through  the  anus  by  fingers  introduced  into  the 
vagina.  This  little  manoeuvre  has  often  been  of  great  use  in  helping 
to  diagnose  lesions  of  the  recto-vaginal  septum  and  in  facilitating 
necessary  operations. 

Rectal  palpation. — I  cannot  give  this  any  other  name  to  distinguish 
it  from  the  touch  properly  so-called,  and  to  express  the  nature  of  this 
far  too  rough  method  of  examination,  which  has  been  too  often 
resorted  to,  on  the  authority  of  Simon,  of  Heidelberg,  who  was  the 
first  to  practise  it.^     It  is  certainly  possible  to  introduce,  not  only 


Fig.  112.— Rectal  combined  with  abdominal  palpation  (after  Simun). 

one  or  two  fingers,  but  the  whole  hand  into  the  rectum  especially  of 
women  when  under  the  influence  of  chloroform,  after  having  forcibly 
but  gradually  dilated  the  sphincter.  The  patient  being  placed  on  her 
back,  the  lower  limbs  and  the  head  are  flexed  on  the  abdomen,  which 

1  Ueber  die  Erweiterring  des  Anns  und  Bectttm,  &c.,  Archiv.  fur  Klinische 
Chirurgie  herausgegcben  von  Langenbeclc,  Billroth  uvd  Ghtrlt,  Band  xv, 
Heft  1,  p.  99,  1872  ;  Gazette  hebdomadaire.  3  Janvier,  1873. 


132  GENEEAL    SUEVEY    OF    UTEEINE    DISEASES 

is  thus  shortened  as  much  as  possible  whilst  the  surgeon  introduces 
first  two  fingers,  then  two  more,  then  the  thumb,  then  the  whole  hand 
well  greased  through  the  anus  with  the  same  precautions  as  are  used 
in  introducing  it  into  a  narrow  vagina  or  into  the  uterus  for  the 
purpose  of  turning  or  for  the  removal  of  the  placenta,  making  small 
incisions  when  requisite  round  this  orifice.  In  spite  of  the  great  dis- 
tension of  the  anal  orifice,  mere  intra-rectal  exploration  does  not 
relax  the  sphincter;  cases  requiring  incision  are  followed  by  fsecal 
incontinence  for  ten  or  twelve  days.  When  the  hand  has  penetrated 
into  the  rectum  as  far  as  the  promontory  of  the  sacrum,  it  is  possible 
to  reach  the  sigmoid  flexure  with  three  or  even  four  fingers,  and 
owing  to  the  mobility  of  the  rectum  we  can  palpate  (through  its 
walls)  the  whole  of  the  abdominal  region  as  far  as  the  kidneys  and 
umbilicus,  and  so  gain  much  information.  In  two  cases  of  ovarian 
cyst  Simon  was  able  to  determine  the  breadth  and  length  of  the 
pedicle,  the  absence  of  adhesions,  and  the  existence  in  the  fundus  of 
the  uterus  of  two  fibromata  of  the  size  of  a  cherry-stone.  Unless  the 
patient  is  very  stout,  we  can  in  this  way  examine  the  ovaries  even 
when  they  are  healthy  and  in  a  normal  position.  It  appears  from  the 
researches  of  Simon  that  the  greatest  circumference  of  the  rectum  is 
at  6  or  7  centimetres  above  the  anus,  and  may  reach  at  this  point  25 
to  30  centimetres.  In  the  upper  part  of  the  middle  third  it  is  only 
from  20  to  25  centimetres,  and  diminishes  rapidly  beyond  that,  being 
only  from  16  to  18  centimetres  in  the  middle  part  of  the  upper  third 
of  the  rectum.  The  narrowest  point  corresponds  to  the  beginning  of 
the  sigmoid  flexure.  Weir,  in  summing  up  these  measurements,  con- 
cludes that  a  hand  measuring  less  than  26  centimetres  in  circumfer- 
ence can  without  danger  penetrate  from  17  to  19  centimetres  but  not 
farther.  It  is  superfluous  to  remark  that  in  this  exploration,  which  is 
only  allowable  in  very  serious  cases,  a  small  hand  is  very  useful,  and 
that  the  greatest  gentleness  should  be  observed  in  the  manoeuvre, 
especially  if  there  is  reason  to  suspect  contraction  of  the  intestine. 
Several  deaths  have  already  occurred  as  the  result  of  this  method. 
Heslop,  of  Birmingham  ('Lancet,^  May  11th,  1872),  relates  two 
cases  of  death  due  to  rupture  of  the  intestine  near  or  at  the  seat  of  a 
contraction.  Three  other  cases  of  death  are  reported  by  Ptobert  Weir 
('Medical  Record,'  New  York,  May  20th,  1875,  p.  201)  occurring 
in  the  practice  of  Sands,  Sabine  and  Weir,  aU  three  due  to  laceration 
of  the  intestine. 

When  an  operation  necessitates  penetration  far  into  the  rectum  we 
may  have  recourse  to  rapid  dilatation  of  the  anus  and  intestine ;  often 
rupture  of  the  sphincter  is  sufficient ;  if  not  we  can  resort  to  lateral 
incisions,  or,  better  still,  to  a  posterior  one,  with  or  without  ablation 
of  the  coccyx.  The  introduction  of  instruments  is  greatly  facilitated  by 
posterior  linear  rectotomy  as  practised  by  Verneuil,  without  haemor- 
rhage, by  means  of  the  thermo-cautery,  and  in  this  way  operations  are 
made  possible  vvhich  would  not  otherwise  be  practicable;  but  these 
operations  are  rarely  required  for  diagnostic  purposes.  Lastly,  when 
ocular  inspection  is  associated  with  touch,  various  kinds  of  specula 


SIGNS    FURNISHED    BY    DIRECT    EXAMINATION  133 

(the  two  best  being  the  univalvular  and  Fergusson's)  may  be  intro- 
duced, and  furnish  us  with  new  and  valuable  elements  of  diagnosis, 
not  only  for  rectal  diseases  but  for  those  of  the  uterus  and  its 
appendages. 

Vesical  touch. — I  must  not  omit  noticing  this  new  mode  of  examina- 
tion, recommended  by  Noeggerath,i  which  may  be  exceptionally  used ; 
it  is  the  association  of  vesical  with  rectal  or  vaginal  touch.  The 
urethra  being  dilated  the  index  finger  is  introduced  whilst  another 
finger  is  in  the  rectum  or  vagina,  the  uterus  in  the  meantime  being 
drawn  down  by  a  fine  tenaculum  hook. 

3.  The  Speculum. — The  speculum  is  a  mirror  reflecting  light  on  the 
neck  of  the  uterus  and  the  distant  parts  of  the  vagina,  whilst  the  vulva 
and  rest  of  the  vaginal  walls  are  dilated  by  it.^  The  one  for  habitual  use 
should  be  one  easily  handled  and,  above  all,  easily  cleaned.  In  these 
respects  there  is  none  superior  to  the  cylindrical  speculum,  slightly 
conical,  of  Recamier  (1814),  or  of  Dupuytren  (1816)  ;  but  this  spe- 
cujum  is  by  no  means  sufficient  for  every  case ;  indeed,  as  applicable  to 
the  largest  number  of  cases,  the  duck  bill  is  preferable.  In  enumerating 
the  various  instruments  of  this  kind  which  are  manufactured  I  will 
mention  those  which  I  use  most  frequently,  as  well  as  those  to  which  I 
have  recourse  only  in  exceptional  cases.  The  tubular  metal  speculum 
is,  as  I  have  said,  most  necessary  to  the  gynecologist.  He  should 
have  several  sizes  and  all  as  long  as  possible.  More  than  once  I  have 
failed  to  reach  the  cervix  owing  to  the  shortness  of  my  speculum.  It 
is  well  to  have  five  sizes  on  account  of  the  variable  dimensions  of  the 
vulva  and  cervix  in  different  women.  It  is  not  enough  that  a  speculum 
enters  the  vulva  ;  it  must  also  fit  the  neck  of  the  womb.  If  the  large 
size  is  most  convenient  for  examination  it  is  not  so  for  the  application 
of  leeches  to  the  cervix,  because  if  this  organ  is  not  exactly  encircled 
by  the  speculum  the  leeches  may  fasten  on  the  vagina  in  place  of  on 
the  cervix. 


Fig.  113. — Cylindrical  speculum  fitted  with  a  plug. 

The  gynecologist  should  also  have  several  sizes  of  Fergusson's  glass 
tubular  instrument,  silvered  and  coated  with  vulcanite;  it  is  more 
easily  introduced  into  a  narrow  vagina,  and  is  also  more  convenient  for 

'  American  Obstetrical  Jov/rnal,  May,  1875. 

^  Verhncs,  MonograpJiie  stir  le  dioptre  ou  speculum.    These  de  Paris,  1848. 


134 


GENERAL    SUEVEY    OF    UTERINE    DISEASES 


reaching  a  retroverted  cervix.  Unfortunately  it  is  very  fragile.  The 
manufacturer  ought  to  try  to  make  it  stronger  by  adding  to  the  thick- 
ness of  the  glass.^ 

Charriere's  trivalvular  speculum  owes  its  great  success  to  want  of 


Fig.  114. — Fergusson's  speculum. 

skill  in  the  ordinary  practitioner.     However,  the  smallest  size  may  be 
useful  in  examining  a  virgin.     This  instrument  has  another  advantage ; 


Fig.  115. — Charriere's  trivalvular  speculum,  fitted  with  a  plug. 

by  removing  one  of  the  valves  it  can  be  turned  into  a  duck-bill,  which 
allows  the  vaginal  wall  to  be  examined.  These  valvular  expanding 
specula  have,  moreover,  a  further  advantage,  owing  to  their  conical 
shape  when  shut  they  can  be  easily  introduced  into  a  narrow  contracted 
vulva  or  where  there  are  fissures,  while  they  dilate  the  vagina  when 
open.  They  were  invented  by  Jobert  (1838)  and  Eicord  (1834),  and 
have  undergone  various  modifications,  one  of  the  most  important 
(due  to  Eicord)  being  that  of  having  the  hinge  on  a  level  with  the 
vulval  orifice,  so  that  when  the  blades  diverge  the  circumference  of  the 
instrument  is  not  increased  at  this  point — an  arrangement  which  pre- 
vents laceration  of  the  vulval  orifice.  This  bivalve  speculum  is  useful 
in  examining  a  large  cervix,  but  it  does  not  sufficiently  protect  the 
vagina  when  applications  have  to  be  made  to  the  cervix^  and  it  also  has 
the  inconvenience  of  allowing  folds  of  a  large  vagina  to  get  between 
the  valves. 

^  As  for  the  opaque  glass  speculum  of  Mayer,  of  Berlin,  it  neither  possesses 
the  advantages  of  Fergusson's  nor  of  the  simple  boxwood  instrument.  It  is 
certainly  necessary  to  have  a  speculum  which  can  protect  the  vagina  from  heat 
when  the  actual  cautery  is  used,  and  which  is  not  affected  by  acids  and  caustics  ; 
hut  I  greatly  prefer  the  simple  boxwood  speculum  on  account  of  its  cheapness 
and  strength,  or  those  of  Leiter,  of  Vienna,  in  vulcanite,  which  are  both  strong 
and  light. 


SIGNS    FURNISHED    BY    DIRECT    EXAMINATION  135 


Charriere  has  made  a  new  bivalve  speculum  for  Cusco  and  Yeiss,  of 
Paris,  and  for  Tyler  Smith,  of  London ;  whilst  preserving  a  constant 


Fig.  116. — Segalas's  quadrivalve  speculum.    1,  a,  shut  with  its  plug  ;  2,  b,  open. 


Fig.  117. — Ricord's  hi-       Fig.  118. — Chairiere's  quadrivalve  speculum, 
valve  speculam.  c,  p,  its  ping. 


136 


OENEEAL    SUEVET   OP   UTERINE    DISEASES 


diameter  at  its  vulval  extremity,  it  allows  the  practitioner  to  separate 
the  two  blades  widely  at  their  uterine  extremity,  so  as  to  expose  the 
cervix  to  view  without  allowing  the  mucous  membrane  of  the  vagina 
to  be  caught  between  the  valves.  Tyler  Smith's  is  of  the  usual  size. 
Cusco's  is  shorter,  so  as  to  avoid  pushing  the  cervix  back  when  it  is 


Fig.  119. — Cusco's  bivalve  speculum. 

low  down,  and  to  allow  of  its  being  examined  nearer.  Its  only  incon- 
venience is  that  it  sometimes  dilates  the  lips  of  the  cervix,  so  as  to  cause 
ectropion,  which  may  lead  the  practitioner  into  error  as  to  the  position 
of  the  OS  externum. 

The  univalvular  speculum  is  indispensable  for  the  examination  and 
treatment  of  diseases  of  the  vagina,  and  especially  for  vesico-vaginal 
fistula  for  which  it  was  invented.  Lallemand  used  a  simple  speculum 
of  this  kind  for  such  cases.  For  a  long  time  I  have  used  similar 
instruments  that  I  made  myself  of  zinc  or  that  I  had  made  in  wood, 
when  I  have  had  occasion  to  perform  operations  in  the  remote  parts 
of  the  vagina.  Hergott,  of  Strasburg,^  was  accustomed  to  use  a 
cylindrical  metal  speculum,  a  great  part  of  which  he  removed  so  as  to 
leave  only  a  spoon  fastened  to  a  handle,  having  the  desired  size  and 


Fig.  120. — One  of  Jobert's  lateral  blades. 
curve.     Jobert  ^  used  long  ago  a  very  ingenious  contrivance  for  dilat- 

*  Perfedionnements   recents  apportes    a   I'operation  de  la  fistule  vesico- 
vaginale.     Sti-asboui-g,  1863. 

2  Traits  de  chirurgie  plastique.     Paris,  1849. 


SIGNS    FUENISHED    BY    DIRECT    EXAMINATION 


137 


ing  the  vagina  in  the  treatment  of  fistula;  he  had  four  blades  of 
different  shapes,  one  of  which  he  applied  to  the  anterior  wall,  another 
to  the  posterior,  and  the  two  remaining  ones  laterally.  I  have  several 
times  found  them  of  great  use.     But  all  these  instruments  are  inferior 


Fig.  121.- 


-Duck-bill  specula,  for  the  operation  for  vesico-vaginal  fistula  by  the 
American  method. 


to  the  duck-bill  specula  invented  by  the  Americans  to  be  used  in 
operating  for  vesico-vaginal  fistula.  In  Marion  Sims's  instrument  ^ 
the  same  handle  carries  two  blades  of  different  sizes.  Bozeman  ^  has 
exaggerated  the  breadth  and  curvature  of  these  blades;  there  may, 
however,  be  cases  where  the  large  dimensions  of  his  instrument  may 
be  useful.     Neugebauer  was  in  the  habit  of  simply  using  two  long 


Fig.  122. — Neugebauer'.s  speculum  modified  by  Barnes. 

metal  blades  regularly  curved,  one  being  inserted  along  the  anterior, 
the  other  along  the  posterior  wall,  so  that  the  two  formed  a  bivalve 
speculum  ;  the  uterine  extremities  of  the  blades  may  be  more  or  less 

'  Silver  Sutures  in  Surgery.  The  Anniversary  Discourse  before  the  New 
York  Academy  of  Medicine.     New  York,  1858. 

^  Follin,  Examen  de  quelques  nouveaux  procedes  operatoires  powr  la  gueri- 
son  des  fistulas  vSsico-vaginales,  Reviie  critique  {Arch.  gen.  de  med.,  5*^  serie, 
t.  XV,  pp.  457,  584).     Paris,  1860. 


138 


GENERAL    SURVEY    OP    UTERINE   DISEASES 


separated,  while  the  vulval  extremities  serve  as  handles.  Barnes  has 
made  various  alterations  in  the  curve  and  size  of  the  valves ;  in  giving 
to  each  of  the  four  extremities  a  different  curve  we  have  specula  with 
different  valves,  and  by  associating  two  together  we  have  four  addi- 
tional specula. 

What  I  find  most  convenient  is  to  have  four  of  Sims's  valves  of 
different  sizes,  and  two  handles;  as  each  of  these  valves  fits  on  to  one 


Fig.  123. — Speculum  made  for  my  own  use  with  four  valves  and  two  handles. 

of  the  handles,  we  can  when  necessary  use  two  valves  at  the  same 
time,  one  to  draw  down  the  posterior  vaginal  wall,  the  other  to  raise 
the  anterior  wall.  I  have  had  such  a  speculum  made  for  myself  and 
use  it  every  day  :  the  smallest  blade  is  a  very  narrow  one  for  virgins, 
the  largest  a  very  broad  one  useful  for  operations ;  by  making  use 
of  two  handles  and  two  blades  simultaneously  my  univalvular  spe- 
culum is  transformed  into  a  bivalve  of  variable  dimensions.  I  have 
similar  valves  made  in  wood,  others  in  vulcanite,  useful  when  acid 
applications  are  made,  or  when  the  actual  cautery  is  employed.  In 
fact  this  instrument  can  when  necessary  replace  all  other  specula, 
whilst  none  can  replace  it.  Therefore  it  is  the  most  fitted  for  daily 
use  when  we  do  not  wish  to  be  cumbered  by  too  many  instruments. 


SIGNS    FURNISHED    BY    DIRECT    EXAMINATION 


139 


It  is  very  easily  introduced ;  all  that  is  required  is  to  push  the  well- 
oiled  blade  along  the  side  of  the  index  finger  of  the  other  hand,  the 
tip  of  which  touches  the  cervix.  The  position  of  the  uterus  depends 
on  whether  the  decubitus  of  the  patient  be  dorsal^  ventral,  or  lateral, 


'  !  "\l  ^ 


Fig.  124. — Two  univalve  specula,  used  as  a  bivalve. 

the  position  chosen  being  important  not  only  for  diagnosis  (which  is 
greatly  facilitated  by  the  examination  of  the  two  cul-de-sacs,  impossible 
with  any  other  speculum)  but  also  for  treatment.  If  the  patient  is  in 
the  pelvi-dorsal  position  we  find  the  cervix  opposite  and  quite  near  us ; 
if  she  is  on  the  left  side,  she  is  in  a  less  strained  position,  and  the  cervix 
is  very  mobile,  a  condition  favorable  to  the  exploration  of  the  vagina 
and  to  the  performance  of  operations  on  it;  if  she  is  in  the  ventral 
position,  the  uterus  is  far  off,  dragged  down  by  the  weight  of  the 
viscera,  which  are  propelled  towards  the  umbilicus  by  the  entrance  of 
air  into  the  vagina  when  the  speculum  is  introduced ;  but  though  the 
cervix  is  far  off,  its  position  is  at  the  same  time  very  convenient  when 
applications  have  to  be  made.  I  should  like  to  take  this  opportunity 
of  warning  young  practitioners  against  making  use  of  any  mechanical 
contrivances  for  fixing  the  speculum  either  to  the  pelvis  of  the  patient 


140 


GENEEAL    SIJRYET    OF   UTEEINE    DISEASES 


or  to  the  operating  table ;  the  patient  is  thereby  exposed  to  serious 
injury  when  she  instinctively  but  involuntarily  shrinks  back  from  the 
operating  instrument.  Surely  the  hand  of  an  assistant  is  preferable  in 
every  respect. 

The  introduction  of  the  cylindrical  and  bivalve  speculum  is  less  easy 
than  that  of  the  simple  univalve;  the  difficulties  are^  to  avoid  giviug 
pain  when  the  instrument  passes  the  vulval  sphincter,  and  to  find  the 
cervix.  Pain  will  be  avoided  if  care  is  taken  to  depress  the  fourchette 
before  passing  the  speculum,  which  should  be  well  oiled.  An  inex- 
perienced practitioner,  when  using  a  cylindrical  or  valvular  instrument, 
will  find  it  advantageous  to  make  use  of  a  wooden  plug  with  rounded 
extremity  projecting  beyond  the  speculum,  which  will  glide  gently 
between  the  labia  into  the  vagina,  and  can  be  removed  as  soon  as  the 
instrument  is  in  place.  The  bivalve  must  be  introduced  transversely 
and  not  perpendicularly,  for  the  anterior  and  posterior  vaginal  walls 
touch,  as  shown  in  Pig.  46,  p.  50.  It  is  not  sufficient  to  be  acquainted 
with  the  normal  direction  of  the  vagina  and  position  of  the  cervix  ; 
before  applying  the  speculum  we  must  always  ascertain  the  exact 


Fig.  125. — Ventral  position. 


Posterior  vaginal  wall  raised  by  univalve 
speculum. 


situation  in  each  case  by  vaginal  touch.  The  speculum  as  well  as  the 
touch  can  be  used  in  the  case  of  virgins  without  injury  to  the  hymen, 
care  being  taken  that  the  legs  are  completely  flexed  on  the  abdomen 
and  kept  close  together,  so  as  to  relax  the  hymen  and  make  it  de- 
pressible.  Of  course  only  instruments  of  the  smallest  size  must  be 
used. 

The  speculum  should  be  oiled  and  shghtly  warmed  before  its  intro- 
duction, otherwise  the  sudden  contact  of  the  cold  metal  with  the 
sensitive  genital  organs  might  cause  contraction  of  the  vulva  and  spasm 


SIGNS    FURNISHED    BY    DIRECT    EXAMINATION  141 

of  the  vagina,  sometimes  even  sharp  pain.  The  patient  being  in  an 
upright  position  by  the  edge  of  a  bed,  sofa,  or  table,  we  ask  her  to  lie 
back,  when  we  raise  the  feet,  flexing  the  legs  gently  on  the  abdomen, 
begging  her  (if  no  assistant  is  present)  to  keep  them  in  this  position 
by  passing  her  hands  under  the  knees.  The  ischiatic  tuberosities 
ought  to  project  as  much  as  possible  over  the  edge  of  the  couch  on 
which  the  patient  is  lying.  I  have  learned  by  experience  that  women 
prefer  this  position  (in  which  it  is  not  necessary  to  uncover  the  patient), 
as  being  more  modest  than  the  one  generally  used  in  Prance,  in  which 
the  patient  has  to  open  her  knees  and  place  her  feet  on  two  chairs 
before  her,  at  a  considerable  distance  from  each  other;  besides,  the 
patient  being  occupied  in  holding  her  knees,  has  her  attention  some- 
what distracted  from  the  examination.  It  is,  moreover,  the  only  suit- 
able position  for  applying  a  speculum  to  a  virgin;  the  legs  being  close 
together  the  hymen  and  fourchette  are  relaxed  and  so  laceration  is 
prevented.  Let  me  advise  all  my  readers  to  follow  my  example  in 
preferring  a  simple  couch,  ottoman  or  table,  to  all  those  ingenious 
mechanical  arm-chairs,  which  only  frighten  patients. 

The  physician,  separating  the  labia  and  nymphse  with  two  fingers 
of  his  left  hand,  examines  the  colour  of  these  organs,  the  state  of  the 
hj-men  and  carunculse  and  of  the  meatus,  ascertaining  whether  there 
is  any  pus  or  leucorrhceal  discharge.  He  depresses  the  fourchette  with 
the  index  finger  of  the  right  hand,  to  judge  as  to  the  rigidity  of  the 
tissues.  Then  taking  the  speculum  between  the  thumb  and  three  first 
fingers  of  the  same  hand,  he  places  the  narrow  end  flat  on  the  four- 
chette, lowering  the  hand  so  that  the  uterine  extremity  of  the  instru- 
ment looks  upwards.  He  then  depresses  the  fourchette,  vulval 
sphincter,  or  hymen  (if  there  is  one),  gradually  bringing  the  axis  of  the 
speculum  into  the  axis  of  the  vulva,  and  by  a  see-saw  motion,  executed 
slowly  and  carefully,  he  inclines  it  more  and  more  towards  the  sacrum^ 
as  in  practising  the  touch.  He  must  beware  of  letting  the  upper 
border  of  the  speculum  come  against  the  meatus,  as  this  might  cause 
pain  and  bleeding.  The  vulva  once  passed,  he  slides  the  instrument 
tc^ards  the  cervix,  following  the  direction  pointed  out  by  the  previous 
examination.  This  organ  is  usually  situated  behind,  the  os  looking 
towards  the  concavity  of  the  sacrum ;  the  easiest  way  of  reaching  it, 
therefore,  is  to  follow  the  posterior  vaginal  wall. 

Daylight  is  always  preferable  to  any  other;  I  have,  however,  often 
been  able  to  examine  and  even  operate  by  artificial  light.  Collin's 
reflecting  lamp  is  the  best;  but  a  good  moderator  or  even  a  candle  is 
sufiicient,  if  an  assistant  with  his  hand,  or,  better  still,  with  a  silver 
spoon,  reflects  the  light  into  the  speculum.  As  the  speculum  slowly 
penetrates  the  vagina  the  surface  of  the  latter  ought  to  be  carefully 
inspected.  We  may  flnd  not  only  redness,  granulations  or  erosions, 
but  ulcers,  vegetations  or  polypi,  as  well  as  mucus,  blood,  pus,  &c., 
excreted  by  the  uterus.  If  the  cervix  when  reached  is  not  in  the 
axis  of  the  speculum,  it  must  be  brought  into  view  with  the  tenaculum 
hook  or  sound,  and  wiped  with  a  pledget  of  cotton  wool.  If  the 
mucus  is  too  adherent  to  be  got  rid  of  by  this  method  it  should  be  re- 


142 


GENERAL    SUEVEY    OF   UTEEINE    DISEASES 


moved  by  injecting  tepid  water,  and  if  this  is  insufficient  we  must  use 
an  emulsion  of  jolk  of  egg,  as  Pajot^  advises.  We  shall  then  be  able 
to  determine  the  positionj  size,  colour  and  external  appearance  of  the 
cervix.     In  short,  the  speculum  confirms  some  of  the  information 

already  furnished  by  touch,  whilst  it  adds 
some  new  facts.  If  the  os  is  directed  back- 
wards (anteversion)  the  speculum  only  dis- 
closes the  anterior  lip  ;  and  in  such  a  case, 
to  bring  the  os  into  the  axis  of  the  specu- 
lum we  must  not  only  have  the  patient's 
legs  well  flexed  on  the  abdomen,  but  we 
must  ask  her  or  an  assistant  to  depress  the 
abdomen  whilst  we  use  the  sound.  In  this 
way  the  fundus  is  lowered  whilst  the  cervix 
is  raised.  If  the  os  looks  forwards  (retro- 
version) we  must  direct  the  speculum  behind 
the  pubis,  and  with  the  sound  try  to  draw 
the  uterine  orifice  backwards.  I  have  some- 
times found  it  useful  to  place  the  patient  on 
elbows  and  knees  or  on  her  side,  in  order  to 
cauterise  the  cervix,  which  I  could  not 
otherwise  have  reached.  We  can  judge  as 
to  the  volume  of  the  cervix  by  the  difficulty 
of  including  it  in  a  cylindrical  speculum,  or 
by  being  obliged  to  have  recourse  to  a 
bivalve.  The  inequalities,  the  consistency, 
the  relative  size  of  the  two  lips  are  visible, 
or  can  easily  be  ascertained  by  exercising 
pressure  on  the  organ  as  a  whole  or  on  each 
of  its  lips. 

The  principal  facts  revealed  by  the  spe- 
culum are :  the  nature,  abundance,  and 
origin  of  morbid  secretions,  the  form  of  the 
orifice,  the  colour  of  the  cervix,  its  ulcera- 
tion or  enlargement,  whether  due  to  hypertrophy  or  the  existence 
of  vegetations.  If  the  cervix  is  dry  it  is  well  to  squeeze  it  with 
the  speculum,  pressing  the  uterus  at  the  same  time  through  the 
abdominal  walls,  to  see  if  by  this  means  we  can  express  a  drop  or 
even  a  flow  of  clear,  milky,  or  purulent  mucus.  It  is  important  to 
ascertain  the  form  of  the  orifice;  it  may  be  a  round  hole  or  a 
transverse  fissure,  all  but  closed  or  widely  open ;  it  may  be  con- 
tinued by  secondary  fissures,  sometimes  bordered  by  cicatricial  tissue 
in  multiparge;  or  there  may  be  ectropion  of  both  hps,  exposing  to 
view  the  cervical  cavity ;  there  may  even  be  inversion,  or,  if  one  may 
so  say,  eversion  of  the  mucous  membrane  of  the  cervix.  The  colour  is 
important ;  it  may  be  pale  pink,  dark  red,  or  even  violet.  The  violet 
colour  of  the  vulva,  vagina  and  cervix  is  not  exclusively  a  sign  of  preg- 
nancy. It  exists  to  some  extent  for  a  few  days  before  and  after  men- 
'  Annales  de  Gynecologie,  t.  t,  p.  464.     Paris,  1877. 


Fig.  126.^Collin's  lamp, 
with  reflector  and  re- 
fracting lens. 


SIGNS    FURNISHED    Bi^    DIRECT    EXAMINATION 


143 


struation.  This  change  of  colour  is  so  marked  and  is  coincident  with 
such  equally  important  changes  in  the  size,  weight  and  consistency  of 
the  organs,  that  I  make  it  a  rule  not  to  examine  a  woman  for  the  first 
time  before  the  eighth  day  after  menstruation,  i.  e.  if  I  wish  to  make 
an  exact  diagnosis  of  the  condition  of  the  uterus.  Eruptions,  erosions, 
ulcers  of  various  kinds,  are  best  seen  at  this  time,  and  cannot  be 
diagnosed  with  precision  by  any  other  means.  The 
same  may  be  said  with  regard  to  slight  granulations  <^ 

and   those  that  are    confluent,  as  well  as  fungous  ^ 

growths  and  small  follicular  cysts. 

What  has  been  said  in  respect  of  other  modes 
of  examination  is  especially  true  of  the  speculum  ;  it 
is  not  only  a  means  of  diagnosis  but  of  treatment. 
It  alone  allows  of  various  applications  being  made  to 
the  cervix  or  to  the  uterine  cavity.  But  we  must  bear 
in  mind  that  this  instrument  ought  not  to  be  unneces- 
sarily used,  as  it  may  irritate  the  urethra,  vagina  and 
cervix,  and  like  all  applications  it  fatigues  the  organ 
when  used  too  often. 

4.  The  Uterine  Sound. — The  sound  is  our  chief 
resource  in  making  an  examination  of  the  uterine 
cavity.  In  the  last  century  Levret  ^  used  one  made 
of  whalebone  for  measuring  the  womb.  In  18iJ8, 
Lair  ^  introduced  Larrey^s  probe  into  the  cervical 
cavity  curving  the  extremity  like  a  catheter,  and  in 
order  to  facilitate  its  entrance  into  the  body  of  the 
womb  he  withdrew  the  speculum  one  third  and  de- 
pressed the  handle  of  the  probe  as  much  as  possible. 
It  is,  however,  only  recently  that  the  sound  has  come 
into  general  use  as  a  means  of  diagnosis  and  treat- 
ment, thanks  to  Simpson,  Huguier,  Yalleix  and 
Kiwisch.  The  circumstances  under  which  this  in- 
strument was  invented  indicate  its  chief  uses.  Val- 
Jeix,  engrossed  with  uterine  displacements,  wanted 
like  Kiwisch  and  Simpson  to  find  an  intra-uterine 
sound  that  would  straighten  the  flexed  uterus  ;  whilst 
Huguier,  having  discovered  hypertrophic  elongation 
of  the  cervix,  invented  the  same  instrument  (calling 
it  a  hysterometer)  to  enable  him  to  measure  the 
cavity.  To  these  uses  we  may  add  that  of  determin- 
ing deviations  in  the  cervico-uterine  ca)ial,  and  above 
all,  the  increased  capacity  of  the  uterine  cavity 
interstitial  fibroma,  polypi,  &c.  When  the  os  is 
situated  in  a  cervix  which  is  conical  and  deviated  from  its  normal 
position,  the  only  means  of  ensuring  the  entrance  of  the  sound  is  to 

'  Sur  un  allongement  considerable  qui  survient  quelquefois  cm  col  de  la 
matrice  ;  Journal  de  medecine  et  de  pharmacie  de  Moux,  Octobre,  1773,  t.  xl, 
p.  352.     Quoted  by  Stoltz,  Gazette  hebdomadaire,  1860. 

'■'  Nouvelle  methode  de  traitement  dcs  ulcerations  de  la  matrice.      PariK, 

1828. 


Fig.  127. — Intra- 
uterine sound 
v.'ith  stem  slid- 
ing into  the 
handle  and  mov- 
able index. 

associated    with 
very   small,  and 


144  GENERAL    SURVEY    OE    UTERINE    DISEASES 

introduce  it  through  the  speculum.  But  after  an  entrance  is  secured  it 
penetrates  more  easily  without  the  speculum  than  with  it.  The  reason 
of  this  is,  that  the  axis  of  the  uterus  is  not  that  of  the  vagina ;  that 
there  is  also  often  a  slight  anteflexion  between  the  neck  and  body  of  the 
womb ;  besides,  there  may  be  abnormal  flexions  or  tumours  causing 
curves  and  angles  in  the  uterine  cavity.  The  uterine  extremity  must 
follow  these  various  curves,  consequently  the  handle  must  be  inclined 
in  a  contrary  direction.  Therefore,  after  the  sound  has  entered  the  os 
the  speculum  ought  to  be  withdrawn  and  the  handle  of  the  sound 
depressed  towards  the  rectum,  so  as  to  allow  the  bulb  to  enter  the  body 
of  the  uterus.  When  it  is  desirable  to  introduce  the  sound  without  the 
speculum,  the  patient  ought  to  be  on  her  back  or  on  the  left  side. 
After  examining  by  touch,  the  tip  of  the  flnger  is  placed  close  to  the  os, 
and  the  sound  is  introduced  by  the  other  hand  (its  concave  side  being 
always  directed  forwards)  ;  guided  by  the  index  finger  the  os  is  easily 
reached  and  entered.  The  finger  ought  then  to  be  placed  behind  the 
cervix,  raising  it  slightly,  whilst  the  sound  is  pushed  gently  forwards 
25  or  30  millimetres.  The  operation  so  far  is  very  easily  performed, 
unless  the  orifice  is  circular  and  very  narrow,  as  is  often  the  case  in 
virgins  and  nulliparse ;  usually  no  pain  is  felt,  unless  the  patient  is 
suft'ering  from  metritis  or  neuralgia.  If  difficulty  is  experienced  in 
passing  the  arhor  vita,  it  will  be  overcome  by  moving  the  sound  very 
gently  from  side  to  side ;  but  it  often  is  not  easy  to  pass  the  os  internum 
without  causing  a  little  bleeding.  The  narrowness  of  the  orifice,  its 
natural  occlusion  owing  to  the  median  columns  of  the  cervix  fitting 
tightly  into  each  other,  the  spasmodic  contraction  of  the  sphincter,  the 
flexion  of  the  body  on  the  neck,  all  conduce  to  make  it  difficult  to  pass 
the  OS  internum.  Indeed,  sometimes  it  is  impossible  to  do  so ;  occa- 
sionally, however,  it  is  passed  very  easily  and  without  causing  any  pain. 
Force  must  never  be  employed  in  order  to  enter  the  uterine  cavity,  by 
pressing  very  gently  in  the  probable  direction  of  the  orifice,  raising  the 
neck  or  body  with  the  finger,  according  to  the  mutual  relationsliip  of 
these  two  parts  as  indicated  by  vaginal  touch,  depressing  the  handle 
for  an  anteflexion,  raising  it  for  a  retroflexion,  or  inclining  it  to  the- 
side  in  the  case  of  a  lateral  flexion,  we  at  last  experience  the  sensation 
of  resistance  overcome,  whilst  the  patient  at  the  same  moment  expe- 
riences more  or  less  acute  pain.  The  instrument  penetrates  to  a 
distance  of  60  to  80  millimetres,  and  can  be  moved  easily,  especially  in 
a  lateral  direction.  When  it  impinges  against  the  fundus  it  sometimes 
causes  a  peculiar  sensation  of  discomfort  and  suffering,  which  "  goes 
to  the  heart,^'  as  patients  say.  I  have  seen  some  women  suffer  very 
acute  pain,  accompanied  by  hysterical  spasms  and  nervousness,  which 
lasted  for  some  hours.  As  the  sound  follows  the  direction  of  the  canal 
the  uterus  is  replaced  in  proportion  as  the  instrument  penetrates,  so 
that  flexions  disappear,  being  sometimes  transformed  into  versions, 
whilst  at  other  times  the  whole  organ  is  brought  back  to  its  normal 
position.  It  is  then  that  the  mobility  of  the  sound  in  the  uterine 
cavity  can  be  observed,  and  that  it  can  be  made  to  describe  circles  more 
or  less  extensive;  and,  at  the  same  time,  before  its  withdrawal  care 


SIGNS    FURNISHED    BY    DIRECT    EXAMINATION  145 


Fig.  128. — Use  of  the  sound  in  retroflexion. 

should  be  taken  to  move  the  index  slide  to  a  level 
with  the  cervix  in  order  to  measure  the  exact  length 
of  the  organ. 

In  the  case  of  a  uterine  fibroma,  anteflexion^  &c., 
the  introduction  of  a  sound  is  very  difficult  and 
painful.  In  place  of  the  ordinary  instrument  it  is 
better  to  use  Sims's  small  flexible  silver  or  copper 
one.  If  we  cannot  reach  the  fundus  with  this  instru- 
ment we  must  use  a  very  small  gutta-percha  bougie, 
because  in  such  a  case  it  is  of  great  consequence  to 
measure  the  exact  length  of  the  uterus. 

We  must  not  persist  in  forcing  the  sound  onwards 
when  we  experience  great  resistance  ;  it  is  better  to 
make  a  second  or  third  attempt,  or  to  delay  it  till 
another  day.  As  a  rule  it  is  more  prudent  to  use 
this  instrument  in  the  middle  of  the  intermenstrual 
period,  when  the  congestion  which  precedes  and 
follows  menstruation  is  not  present ;  however,  if  we 
cannot  succeed  then,  we  may  take  advantage  of  the 
menstrual  period  or  the  day  following  (when  the 
orifices  are  dilated)  to  penetrate  into  the  cavity  and 
to  dilate  the  os  internum ;  but  in  doing  so  we  must 
use  extra  precaution. 

The  use  of  the  sound  may  be  contra-indicated ; 
for  instance,  by  pregnancy.     To  avoid  all  risks  the 


»■ 


Fig.  129.— a  a, 
arc  of  a  circle 
described  in  the 
uterine  cavity 
by  the  bulb  of  a 
sound  moving; 
round  a  fixed 
point  B  h,  at  the 
OS  externum. 
JU 


146  GENERAL    SURVEY    OF    UTERINE   DISEASES 

practitioner  should  never  use  the  sound  without  receiving  an  assurance 
that  the  patient  has  had  no  coitus  since  her  last  monthly  period^  and 
having  satisfied  himself  that  the  usual  presumptive  signs  of  pregnancy 
are  absent.  The  use  of  this  instrument  is  also  contra-indicated  at  the 
menstrual  period,  especially  when  menstruation  is  abundant  and  painful 
and  associated  with  considerable  congestion,  as  well  as  in  an  inflamma- 
tory condition  of  the  uterus,  in  suppuration  of  the  mucous  membrane, 
in  acute  catarrh,  in  ovaritis,  in  acute  pelvic  peritonitis,  in  an  organic 
disorder  such  as  cancer  or  softening  of  the  tissues  of  the  body  of  the 
uterus,  or  in  the  few  weeks  following  delivery.  Care  must  also  be  taken 
not  to  use  force  in  pressing  the  bulb  of  the  sound  against  the  uterine 
walls  for  fear  of  lacerating  or  perforating  them.  Such  accidents  have 
occurred,  and  although  they  have  seldom  been  followed  by  serious  con- 
sequences we  must  remember  there  is  a  great  difference  among  women 
as  to  sensitiveness.  Several  cases  of  death^  have  been  recorded  as  the 
result  of  the  imprudent  use  of  this  instrument.  Unless  the  uterus  is  per- 
fectly mobile  it  ought  never  to  be  lifted  up  by  the  sound,  nor  should 
abdominal  palpation  be  combined  with  the  use  of  this  instrument,  for 
in  pushing  it  against  the  fi^ngers  which  depress  the  hypogastrium  we 
run  the  risk  of  perforating  the  uterus. 

"Whilst  admitting  that  the  sound  requires  to  be  used  with  great  care, 
I  think  all  gynsecologists  will  agree  with  me  in  considering  it  indis- 
pensable in  the  diagnosis  of  a  certain  number  of  uterine  diseases.  If 
we  remember  that  normally  the  uterus  is  slightly  anteflexed,  that  the 
relative  lengths  of  neck  and  body  are  anatomically  determined,  that 
in  a  state  of  health,  especially  in  the  nullipara,  a  cavity  of  the  body 
cannot  be  said  to  exist,  the  two  walls,  being  in  close  juxtaposition, 
only  allowing  shght  lateral  movements  to  any  instrument  that  may  be 
introduced,  and,  lastly,  that  the  smooth  mucous  membrane  protected 
by  epithelium  is  not  liable  to  be  torn  by  a  blunt  instrument  nor  to 
bleed  unless  there  is  congestion,  we  may  conclude  that  examination  by 
the  sound  will  be  of  great  use  in  giving  us  necessary  information  on 
the  following  points  : — 1.  The  dimensions  and  entire  length  of  the 
uterus,  and  consequently  its  volume.  2.  The  relative  dimensions  of 
the  cavity  of  the  body  and  neck,  the  latter  being  sometimes  short, 
whilst  the  former  is  long  and' inflamed  ;  at  other  times  the  neck  only 
is  long,  being  more  than  three  quarters  of  the  whole  length,  presenting 
thus  a  true  hypertrophic  elongation.  3.  The  differences  of  size  in 
other  directions,  the  dilatation  of  the  uterine  cavity  being  easily  per- 
ceived by  gently  moving  the  sound.  4.  Irregularities  of  the  surface, 
alterations  in  the  form  of  the  cavity,  fibromata,  polypi,  vegetations, 
fungous  growths,  and  the  hsemorrhage  which  accompanies  them.  5. 
The  absolute  and  relative  position  of  the  uterus  and  of  its  two  segments 
with  regard  to  each  other,  deviations,  flexions,  and  the  dift'erential 
diagnosis  between  these  displacements  and  polypi,  fibromata,  whether 
interstitial  or  pediculated,  utero -peritoneal  adhesions,  extra-uterine 
tumours,  peri-uterine  abscess,  hsematoceles,  ovarian  cysts,  &c.  6. 
Stenosis,  deviations,  and  spasmodic  contractions  of  the  uterine  orifices. 
'  L.  E.  Dupuy,  Progres  medical,  pp.  109,  171,  195.     Paris,  1873. 


SIGNS    FDENISHED    BY    DIRECT    EXAMINATION 


147 


7.  Lastly,  the  accumulation  of  fluids  in  the  uterine  cavity,  which  can 
be  diagnosed  by  means  of  the  hollow  sound,  which  at  the  same  time 
affords  a  means  of  ascertaining  the  comparative  dilatation  of  this 
cavity. 

II.  Cowplementary  means  of  exploring  the  Uterine  Cavity. — 
The  greater  part  of  these  are  means  of  treatment  as  well  as  of 
diagnosis.     I   will,    however,    describe  them  here,    because    though 


Fig.  130. 


Fig.  131. 


Fig.  133. 


Fig.  130. — Joljevt  de  Lamballe's  intra-uterine  speculum. 

Fig.  131. — Mathieu's  small  speculum  or  uterine  dilator. 

Fig.  132.— Bivalve  uterine  dilator  (Lemenant-Deschenais). 

Fig.  133. — Trivalve  uterine  dilator  (Busch,  modified  by  Huguier). 


148 


GENEEAL   SUEVEY    OP    UTEEINE    DISEASES 


there  is  only  one  way  of  using  them  when  they  are  employed  as  a 
means  of  diagnosis^  their  use  varies^  on  the  contrary,  according  to 
the  exigencies  of  the  case  when  they  are  employed  as  a  means  of 
treatment. 

T/ie  hitra-nterine  speculum  is,  I  think,  the  least  useful  of  all  instru- 
ments. There  are  various  kinds,  one  of  them  (that  of  Desormeaux) 
being  really  a  speculum,  ^.  e.  a  mirror  enabling  us  to  see  different  parts 
of  the  intra- uterine  mucous  membrane;  the  others  serve  also  as  dila- 
tors. I  may  mention  those  of  Atthill,^  Jobert,  Mathieu  and  Blatin, 
the  bivalve  of  Lemenant-Deschenais,  the  trivalve  of  Busch  modified  by 
Huguier,  &c.  Peaslee'^  has  also  invented  a  somewhat  similar  instru- 
ment. It  is  a  silver  tube,  7  to  8  millimetres  in  breadth,  5  to  6  cen- 
timetres in  length,  with  a  conical  end,  through  which  are  three 
openings,  which  not  only  afford  a  view  of  the  fundus,  but  also  allow 
of  the  introduction  of  the  very  finest  instruments,  of  vegetable  or 
metallic  threads,  &c. 

The  dilator  is  more  useful.  I  may  mention  Aussandon's  instru- 
ment, made  of  prepared  wood  or  ivory,  which,  when  placed  in  the 
uterus,  swells   to  double   its   size.     Dilatation,  however,  is  effected 


«Basz2aa2£2M^>— 


Fig.  134. — Aussandon's  uterine  dilator. 


more  surely  and  safely  by  means  of  ordinary 
bougies  or  by  Simpson''s  metallic  stems  (of 
tin,  silver,  or  aluminium)  of  gradually  in- 
creasing size,  terminating  in  a  bulb,  which 
supports  the  cervix.  But  the  best  of  all 
means  of  dilatation  are  tents  of  prepared 
sponge  or  laminaria,  which  expand  so  slowly 
and  gradually  that  the  dilatation  of  the  uterine 
cavity  and  orifices  is  attended  by  no  danger, 
and  very  often  by  no  suffering. 

1.  Sponge  tents  should  be  prepared  in  the  fol- 
lowing way  : — Take  a  piece  of  sponge  of  conical 
shape,  soak  it  in  a  strong  solution  of  gum,  fix  it 
on  a  central  stem,  and  compress  it  as  forcibly 
as  possible  by  binding  it  round  with  string ;  dry 
it  thoroughly,  remove  the  string,  file  off  any 
roughnesses,  and  cover  it  with  lard  or  wax  to 
facilitate  its  introduction,  which  is  efl'ected  by 
inserted  in  the  centre  of    the  sponge,  or  simply 


Fig.  135. — Simpson's 
large  intra-uterine 
pessary. 

means  of   a  stem 

»  Dublin  Journal  of  Medical  Sciences,  January,  1873,  p.  73. 
'  Intra-uterine  Medication :  its  Uses,  Limitations  and  Methods,  by  M.  D. 
Peaslee.     New  York  Medical  Journal,  July,  1870,  p.  481. 


SIGNS   FURNISHED    BY  DIRECT    EXAMINATION  149 

by  the  uterine  forceps.     These  tents  should  be  made   of  different 
sizes,  varying  in  diameter  from  2  to  10  millimetres  and  in  length 


Fig.  136. — Sponge  tent  with  introducer. 

from  2  to  7  centimetres.  Before  introducing  one  I  cover  it  with 
belladonna  ointment  (Ext.  Bellad.  gr.  xv,  lard  gr.  Ix).  After  its 
insertion  I  pour  two  spoonfuls  of  glycerine  into  the  vagina,  and  then 
place  a  plug  of  cotton  wool  to  keep  the  tent  in  its  place.  The 
glycerine,  whilst  determining  a  very  abundant  serous  secretion,  dis- 
infects this  leucorrhceal  discharge  entirely.  The  tent  is  left  for 
twenty-four  hours,  when  the  patient  can  remove  it  herself  by  means 
of  a  thread  attached  to  it,  and  which  is  long  enough  to  hang  out- 
side the  vulva.  The  dilatation  generally  takes  place  without  suffering ; 
sometimes,  however,  the  patient  has  pains  like  those  of  menstrua- 
tion. If  the  sponge  is  left  for  more  than  twenty-four  hours,  it  is 
generally  expelled  spontaneously  into  the  vagina,  probably  from 
pressure  of  the  mucus  secreted  above,  aided  by  uterine  contractions. 
However,  if  it  is  pushed  high  up  into  the  cervical  cavity,  so  that  the 
OS  externum  closes  over  it,  extraction  may  be  necessary,  especially  if 
the  thread  breaks,  as  sometimes  happens.  The  sponge  itself  may  tear, 
a  part  being  retained  for  months  adhering  to  the  mucous  membrane. 
After  having  withdrawn  the  sponge  the  patient  ought  to  take  an 
emollient  bath  for  an  hour,  injecting  water  from  the  bath  into  the 
vagina  all  the  time.  A  second  sponge  may  be  introduced  immediately 
afterwards,  but  it  is  more  prudent  to  allow  the  patient  to  rest  for  one 
or  two  days.  The  vaginal  injections  ought  to  be  made  very  slowly, 
for  I  have  sometimes  seen  the  occurrence  of  uterine  colics,  evidently 
caused  by  the  fluid  penetrating  into  the  uterus. 

By  taking  these  precautions,  occasionally  making  an  examination  by 
speculum,  and  suspending  the  dilatation  as  soon  as  any  signs  of  irrita- 
tion appear,  we  may  in  a  few  weeks — sometimes  in  a  few  days — dilate 
the  cavity  sufficiently  to  be  able  to  explore  its  surface  thoroughly  with 
the  finger,  and  even  with  instruments.  During  this  time  the  ])atient 
ought  to  remain  in  bed  and  take  an  emollient  bath  every  day.  When 
the  OS  externum  is  too  narrow  to  allow  of  the  entrance  of  a  tent, 
incision  of  the  orifice  must  be  practised,  but  even  after  this  incision 
has  been  made  it  is  often  necessary  to  use  tents  to  dilate  the  cervix 
and  OS  externum.  If  M-e  have  any  reason  to  suspect  cancer  we  cannot 
exercise  too  much  care  in  dilating  and  examining  the  uterus,  lest  the 
substance  should  be  torn  and  the  wall  perforated,  as  in  a  case  I 
have  seen. 

2.  Laminaria   digitata  is   soft,   flexible,    and   loses   much   of  its 


150  GENEEAL    SURVEY    OF    UTERINE    DISEASES 

diameter  when  dried.  Its  structure  being  cellular,  it  dilates  greatly 
under  the  influence  of  moisture,  reaching  a  volume  of  five  or  six  times 
its  original  size.  The  mucous  secretions  are  generally  sufficient  to 
effect  thiSj  but  simple  injections  may  be  used  if  necessary.  The  young 
stems  are  the  best,  the  size  varying  according  to  the  case.  The  rind 
should  be  retained,  and  one  end  should  be  pointed,  whilst  the  other 
has  a  thread  attached  to  it.  The  tents  before  being  used  should  be 
well  washed  and  then  damped  and  dried  successively  several  times. 
Laminaria  tents  act  as  efficiently  and  quickly  as  prepared  sponge 


(^^ 


Fig.  137. — Laminaria  tent  polisBed  and  perforated. 

and  are  better  in  some  respects ;  they  are  more  easily  introduced  when 
the  OS  is  very  small,  and  they  cannot  break.  They  can  be  used  indefi- 
nitely if  care  be  taken  to  wash  them  in  a  solution  of  permanganate  of 
potash,  they  are  more  quickly  and  easily  prepared,  they  are  abundant 
and  cost  almost  nothing;  but  in  spite  of  these  advantages  they  cannot 
as  a  rule  replace  sponge  tents  beneficially.  Sometimes  the  constricted 
OS  is  very  unyielding,  and  prevents  the  laminaria  from  dilating  to  its 
full  size  at  this  point,  as  it  does  higher  up,  so  that  the  tent  is  firmly 
retained,  and  cannot  be  withdrawn  without  incision  of  the  orifice. 
Although  incision  of  the  os  externum  is  not  attended  with  danger,  it  is 
different  with  the  internal  orifice,  incision  of  which  is  dangerous,  and  any 
attempt  to  withdraw  the  laminaria  without  incision  is  more  dangerous 
still.  1  have  seen  a  case  where  attempts  at  extraction  produced  pro- 
lapsus of  the  uterus,  with  evident  laceration  of  the  peritoneum,  which 
brought  on  acute  inflammation  and  almost  caused  death.  Nothing  of 
the  kind  is  to  be  feared  with  sponge  tents,  therefore  it  is  clear  that 
they  should  have  the  preference. 

Artificial  prolapsus  of  the  vterus  is  another  means  of  diagnosis  that 
ought  not  to  be  omitted.  This  can  be  effected  without  danger,  and 
even  without  pain,  by  seizing  the  cervix  or  one  of  its  lips  with  the 
uterine  forceps  or  a  fine  tenaculum  hook,  and  exercising  moderate  but 
continuous  traction  till  the  os  is  on  a  level  with  the  vulva.  If  the 
cervix  has  been  naturally  dilated  by  a  tumour  or  artificially  by  a  sponge 
tent,  the  finger  may  then  be  introduced  into  the  cervix,  and  even  into 
the  body  of  the  uterus,  in  order  to  examine  it  thoroughly.  The  same 
means  ought  often  to  be  employed  for  treatment,  to  facilitate  the 
ablation  of  polypi  as  well  as  for  several  other  operations  practised  on 
the  uterus. 


CHAPTER  II. 


XEEATMEXT  OF  UTERINE  DISEASES  IN  GENEEAL — INDICATIONS  TO  BE  FULFILLED 
IN  THE  TEEATMENT  OF  UTEEINE  DISEASES — METHODS  OF  TEEATMENT 
AND  TAEIOUS  MEDICATIONS  IN  UTEEINE  DISEASES — MEANS  OF  FULFILLING 
INDICATIONS   IN   THE   TEEATMENT   OF    UTEEINE   DISEASES. 

To  institute  a  rational  treatment,  it  is  necessary  first  of  all  to 
lay  down  the  indications  and  contra-indications ;  afterwards  to 
seek  the  best  means  of  fulfilling  these  indications.  I  have  con- 
siderable difficulty  with  regard  to  the  indications,  because  of  their 
infinite  variety  in  diseases  of  the  womb.  If  it  is  difficult  to  describe 
them  correctly,  it  is  more  difficult  still  to  lay  down  exact  treat- 
ment. In  practice  it  is  of  the  first  importance  to  remember  that 
it  is  our  patients  whom  we  have  to  treat  and  not  abstract  diseases. 
However  exact  our  descriptions  and  precepts  may  be,  they  can  only 
represent  types  undergoing  modifications  which  it  is  impossible  to 
foresee  ;  therefore,  in  applying  general  rules  to  any  individual  case,  a 
large  margin  must  be  left  to  the  judgment  of  the  attending  physician. 
In  spite  of  these  difficulties  we  can  place  some  finger  posts  which  will 
help  to  keep  us  in  the  right  road.  In  considering  the  question  from 
this  point  of  view  I  shall  lay  down  some  general  principles  to  serve  as 
a  basis  for  a  system  of  therapeutics  as  apphed  to  uterine  diseases  in 
general,  from  which  can  be  deduced  the  special  treatment  most  suitable 
to  each  particular  case. 

1.  The  first  indication  is  the  necessiti/  for  treatment.  It  may  seem 
superfluous  to  make  this  remark,  but  it  is  not  really  so.  There  are  so 
many  acute  and  even  chronic  diseases  cured  by  nature  that  it  is  neces- 
sary to  point  out  how  different  uterine  diseases  are  in  this  respect. 
In  their  case  the  expectant  method  is  deplorable,  although  very  useful 
in  many  other  circumstances.  Experience  teaches  us  that  diseases  of 
the  womb  have  no  tendency  to  spontaneous  cure.  Nothing  can  be 
hoped,  even  from  the  changes  and  evolutions  which  the  uterus  under- 
goes at  dilTerent  periods  of  life  in  passing  from  childhood  to  puberty, 
from  puberty  to  the  period  of  sexual  activity,  and  from  that  to  old 
age.  Neither  menstruation  nor  the  menopause  has  any  tendency  to 
cure  uterine  diseases.  Menstruation,  on  the  contrary,  brings  a  great 
many.  The  menopause  certainly  has  a  tendency  to  lessen  some  dis- 
eases by  the  cessation  of  periodical  ovulation  with  its  accompanvin" 
fluxion  and  hasmorrhage  ;  but  habitual  fluxions  do  not  always  cease  ; 
on  the  contrary,  they  sometimes  seem  to  assume  a  character  of  greater 
intensity  from  having  lost  their  regulator.  It  is  the  same  with  passive 
congestions  which  no  longer  have  their  periods  for  disappearing  in 


152         TEEATMENT    OP    UTEEINE    DISEASES    IN    GENERAL 

the  normal  alternations  of  uterine  plethora  and  depletion.  Besides, 
various  constitutional  affections  are  apt  to  show  themselves  at  the 
climacteric  period,  so  that  if  one  danger  is  removed  another  is  brought 
on.  As  for  the  changes  occurring  in  the  sexual  period,  they  are 
hurtful  in  place  of  benig  favorable  to  uterine  diseases,  often  helping 
to  perpetuate,  hardly  ever  to  cure  them.  Beware  of  hoping  that 
marriage  will  cure  a  uterine  disease.  At  the  most  it  can  only  regulate 
or  increase  defective  menstruation,  and  will  certainly  aggravate  any 
real  morbid  condition ;  for  one  disease  that  pregnancy  has  ameliorated 
or  cured  (supposing  the  retrograde  evolution  of  the  womb  to  have  been 
well  directed)  it  has  aggravated  a  thousand.  It  is  of  consequence  to 
have  clear  ideas  on  this  point,  that  the  physician  may  be  able  to  con- 
vince his  patients  of  its  importance,  so  as  to  make  them  willing  to 
continue  treatment  as  long  as  is  necessary.  We  must,  however, 
remember  that  every  functional  disturbance  or  displacement  of  an 
organ  is  not  a  disease.  This  term  should  be  reserved  for  those  changes 
in  the  generative  system  which  are  accompanied  by  functional  disturb- 
ance, abnormal  phenomena,  or  pathological  processes  in  this  system  or 
in  the  general  economy  incompatible  with  the  free  exercise  of  special 
or  general  organic  functions,  or  with  the  continuance  of  life.  Such 
are  the  limits  beyond  which  we  ought  not  to  venture  in  pursuing  a 
vigorous  treatment,  which  cases  recently  reported  (especially  with 
regard  to  displacements)  show  not  to  be  exempt  from  danger. 

2.  Under  certain  circumstances  we  must  content  ourselves  with  a 
palliative  cure  and  not  continue  treatment  when  a  perfect  cure  is  im- 
possible, as  unfortunately  is  too  often  the  case.  Por  example,  how 
can  we  hope  for  the  radical  cure  of  interstitial  and  multiple  tumours, 
pediculated  subperitoneal  tumours,  of  ovarian  cysts  when  sufficiently 
tolerated  by  the  organ  not  to  necessitate  extirpation,  in  short,  of  all 
material  changes  which  are  the  starting  point  of  functional  troubles 
which  art  is  powerless  to  remedy,  or  at  least  which  it  cannot  attempt 
without  exposing  the  patient  to  greater  dangers  than  those  of  the 
disease  itself ;  therefore  we  are  often  obliged  to  limit  ourselves  to  a 
palliative  cure,  simply  regulating  the  functions  of  the  sexual  organs 
and  of  the  general  economy.  By  venturing  further  and  employing 
more  energetic  means  we  expose  ourselves  to  terrible  reactions  and 
even  to  an  exacerbation  of  the  disease  itself;  or  if  we  succeed  in  sup- 
pressing it  we  may  determine  serious  disturbance  of  the  whole  economy 
or  the  appearance  of  a  dangerous  disease  such  as  phthisis,  which  till 
then  was  latent,  in  another  organ.  It  is  all  the  more  important  that 
we  should  restrict  ourselves  to  palliative  measures  in  certain  cases, 
as  the  perfect  integrity  of  the  uterus  and  its  appendages  is  not  abso- 
lutely indispensable  to  the  exercise  of  sexual  and  general  functions. 
Experience  teaches  us  that  women  may  be  affected  by  organic  dis- 
orders of  this  system  without  being  greatly  inconvenienced  by  them. 
These  disorders  are  often  not  only  compatible  with  the  free  exercise  of 
the  general  functions,  but  even  with  the  accomplishment  of  the  special 
functions  of  the  sexual  economy.  Pibrous  tumours  and  ovarian  cysts 
do  not  always  prevent  conception  nor  induce  abortion. 


INDICATIONS    FOE   TEEATMENT  153 

Very  often  we  must  limit  our  aim  to  the  disappearance  of  functional 
disorders,  pain,  hgemorrhage,  leucorrhoea,  and  other  morbid  phenomena 
with  the  restoration  of  the  general  health.  In  morbid  conditions 
characterised  by  functional  trouble,  such  as  disorders  of  menstruation, 
or  by  pathological  processes  unaccompanied  by  neoplasm,  functional 
restoration  usually  coincides  with  the  radical  cure  of  the  disease,  the 
treatment  having  attained  both  ends  at  the  same  time.  In  displace- 
ments and  deviations,  as  well  as  in  diseases  characterised  by  the 
existence  of  neoplasm  or  organic  alterations,  it  is  possible  to  regulate 
function  without  restoring  integrity  of  the  structure  or  the  position  of 
the  organs ;  and  treatment  need  not  be  prolonged  after  the  first  of 
these  results,  a  palliative  cure,  has  been  obtained. 

3.  When  we  consider  how  seldom  it  happens  that  the  uterus  is  for 
a  long  period  the  seat  of  morbid  processes  without  its  organic  tissue 
becoming  more  or  less  seriously  affected  and  how  little  tendency 
uterine  diseases  have  to  spontaneous  cure,  we  must  see  the  importance 
of  another  indication  :  viz.  the  necessity  of  always  associating  general 
with  local  treatment. 

In  general  affections  of  the  organ  and  in  purely  diathetic  diseases, 
especially  when  the  localisation  is  multiple,  or  when  the  accompanying 
material  change  is  insignificant,  it  will  be  readily  understood  that  not 
only  are  general  means  of  treatment  the  most  important,  but  that 
usually  they  are  of  themselves  sufficient  to  produce  a  definite  cure ; 
in  the  same  way  local  treatment  may  suffice  for  traumatic  lesions, 
changes  of  position,  or  the  development  of  neoplastic  tumours, 
whether  homeomorphous  or  not,  and  even  when  produced  by  the 
localisation  of  a  diathetic  afi'ection.  But  although  local  suffering  may 
be  relieved  and  the  general  health  improved  by  one-sided  treatment,  it 
is  very  seldom  that  a  permanent  cure  can  be  effected  without  combin- 
ing general  and  local  means  of  treatment.  The  one  or  other  may 
require  most  attention  according  to  the  case;  but  they  cannot  be 
separated,  nor  can  the  one  be  sacrificed  to  the  other.  Aran^  has 
made  the  same  remark,  and  it  is  strikingly  illustrated  in  the  diS'erence 
between  our  private  and  hospital  practice.  In  private  practice  patients 
often  refuse  local  treatment,  either  because  of  the  pain  which  they 
fear  as  a  consequence  of  energetic  measures  or  from  repugnance  to  sub- 
mitting to  the  frequent  applications  and  various  little  operations  which 
may  be  necessary.  On  the  other  hand,  they  are  most  willing  to  carry 
out  any  general  treatment  either  internal  or  external,  even  baths  and 
hydropathy  when  advised.  Under  the  influence  of  such  a  regimen  I 
have  often  seen  the  appetite  restored,  digestion  regulated,  nutrition 
increased,  flesh  gained,  strength  recovered.  But  the  uterine  pain 
never  disappears,  a  real  cure  is  never  effected ;  in  short,  the  temporary 
improvement  does  not  last  more  than  a  few  months,  when  the  patients 
fall  back  into  their  former  state  of  ill-health  and  all  has  to  begin  over 
again.  Hospital  patients,  on  the  other  hand,  are  obliged  to  undergo 
local  treatment,  all  necessary  operations  are  performed,  dressings  made, 
&c.     But   it  is   seldom   that  general  treatment  is  carried  out  with 

1  Op  cit.,  p.  162. 


154         TREATMENT    OF    UTERINE    DISEASES    IN    GENERAL 

necessary  regularity.  Some  patients  consider  all  drugs  poison,  and 
often  manage  to  throw  their  medicine  away,  whilst  baths,  mineral 
waters,  food  and  ventilation  are  often  also  defective  owing  to  the 
limited  resources  of  the  hospital.  In  these  cases  I  have  noticed 
that  the  local  symptoms — pain,  tumefaction,  granulations,  ulcers, 
leucorrhoea — may  disappear  temporarily,  but  if  the  general  health 
does  not  improve  proportionately  with  the  local  disorders  the  latter 
soon  re-appear. 

4.  An  appropriate  treatment  should  be  applied  to  every  disease. — 
It  may  seem  superfluous  to  point  out  this  indication,  but  whilst  it 
certainly  would  be  so  in  reference  to  any  other  class  of  diseases,  it  is 
not  so  with  regard  to  uterine  pathology  ;  this  is  only  explicable  by  the 
relative  ignorance  of  our  predecessors  as  to  the  variety  of  diseases  of 
tbe  womb.  We  must  remember  that  in  uterine  pathology,  as  in  the 
pathology  of  any  other  organ,  there  are  species  and  varieties  differing 
so  much  from  each  other  as  to  require  differences  of  treatment.  The 
most. characteristic  feature  of  the  progress  of  uterine  pathology  in  our 
day  is  the  tendency  to  distinguish  the  different  diseases  of  the  uterus 
as  we  distinguish  different  diseases  of  the  lungs  or  heart,  by  their 
symptoms,  their  organic  lesions  and  their  nature.  The  most  practical 
application  of  this  nosological  distinction  is,  without  doubt,  the 
general  indication  to  vary  the  treatment  according  to  the  case,  and 
to  distinguish  the  special  indications  arising  from  the  differential 
diagnosis  of  the  various  diseases.  I  meet  so  many  medical  men  who 
have  kept  up  the  habit  of  treating  all  uterine  diseases  in  exactly  the 
same  way  (the  treatment  varying,  not  with  the  patient  but  with  the 
doctor)  that  I  must  take  this  opportunity  of  warning  young  practi- 
tioners against  all  uniform  and  stereotyped  therapeutics.  Lisfranc  did 
not  escape  this  error.  His  opinion  as  to  the  frequency  of  engorge- 
ment, which  he  looked  on  as  the  basis  of  all  uterine  pathology, 
necessarily  led  him  to  prescribe  for  the  majority  of  these  diseases  a 
common  treatment,  which  we  find  reproduced  almost  word  for  word 
in  his  consultations.  The  chief  points  of  this  treatment  were  as 
follows  : — Eest  on  the  sofa,  baths  twice  a  week,  conium  internally, 
bleeding  from  the  arm  once  a  month  ;  lastly,  the  gradual  reduction  of 
food  to  the  minimum  quantity  required  to  sustain  life,  with  the  idea 
that  organic  resolution  is  promoted  by  abstinence — ciira  /amis} 
Nonat  has  also  adopted  this  mode  of  treatment,  though  not  so  ex- 
clusively. Others  have  made  almost  all  uterine  pathology  to  consist 
in  replacing  the  womb,  whilst  others  insist  far  too  much  on  antiphlo- 
gistics.  Some  wear  out  the  uterus  by  continual  applications  ;  others 
limit  themselves  to  the  use  of  general  means.  One  practitioner  in- 
variably gives  hot  baths,  a  second  cold  baths  ;  some  prescribe  hip- 
baths, others  general  baths.  Now,  we  cannot  guard  ourselves  too 
carefully  against  any  exclusive  treatment  of  uterine  diseases  in  general, 
or  of  any  special  means  in  particular.  Disease  varies  in  form  and 
nature  in  the  uterus  as  in  other  organs ;  treatment  ought  to  vary 
likewise. 

'  Bulletin  dc  VAcademie  de  Medecine. 


INDICATIONS    FOR    TEEATMENT  155 

5.  It  is  very  important  to  consider  the  nature  of  the  disease. — 
Uterine  diseases  are  very  seldom  of  a  reactionary  nature ;  on  the 
contrary,  tbey  may  be  classified  as  affective  diseases,  i.  e.  dependent  on 
a  general  state.  It  is  not  that  the  general  condition  from  which  they 
derive  their  nature  has  always  been  the  determining  cause  of  their 
development ;  but  it  impresses  its  character  on  the  disease  whether 
primarily  or  not.  They  may  arise  in  two  ways,  either  following  the 
development  of  a  general  affection  or  being  produced  by  a  disease 
originally  local.  The  diathetic  affection  exists;  it  has  already  given 
proof  of  its  existence,  though  it  has  not  yet  attacked  the  uterus. 
However,  it  is  not  long  before  it  fixes  itself  there,  because  this  organ 
is  more  disposed  than  any  other  to  be  affected,  owing  to  its  position, 
its  inclination,  its  monthly  congestion,  the  increased  vitahty  developed 
in  it  by  pregnancy  and  the  traumatism  determined  by  an  abortion  or 
by  delivery.  The  diathetic  affection  manifests  itself  spontaneously; 
at  most  it  only  awaits  a  favorable  opportunity  for  taking  possession. 
At  other  times  the  uterus  is  predisposed  to  disease.  Menstrual 
troubles,  sexual  excess,  over-fatigue,  a  miscarriage  or  difficult  labour 
cause  congestion,  engorgement,  hypertrophy.  Disease  is  established. 
That  would  be  of  no  consequence  if  the  woman  were  healthy  and 
strong;  all  would  then  disappear  with  a  few  simple  precautions.  If, 
however,  a  diathetic  tendency  be  present  the  tendency  becomes  a 
localised  affection,  it  fixes  on  the  uterus,  impressing  its  special 
character  on  the  already  existing  disease.  What  occurs  to  a  man 
suffering  from  blenorrhagia  or  engorgement  of  the  prostate  happens 
to  the  woman  affected  by  uterine  disease.  These  illnesses  when  recent 
and  uncomplicated  are  easily  cured  in  vigorous  individuals.  But 
given  the  existence  of  a  special  diathesis,  these  maladies  open 
the  door  to  the  inroads  of  an  affection  tiU  now  latent,  and  cure  is 
difficult. 

6.  That  we  may  perceive,  therefore,  the  leading  indication,  it  is 
necessary  first  of  all  to  determine  the  diathetic  affection  which  is  the 
essential  cause  of  the  malady.  Any  constitutional  disease  may  become 
localised  in  the  uterus;  it  is  certainly  so  with  cancer,  rheumatism, 
gout,  herpetism,  scrofula,  syphilis,  &c.  I  do  not  think  that  any 
practitioner  can  doubt  the  correctness  of  ray  statement  with  regard  to 
the  majority  of  the  affections  just  named.  I  myself  for  a  long  time 
retained  doubts  as  to  gout;  but  lately  I  have  seen  a  case  which  seems 
to  me  sufficiently  conclusive  to  force  conviction. 

Case. — A  lady,  aged  forty-five,  is  mother  of  two  grown  up  children  in  good 
health  ;  her  father  is  gouty,  her  mother  comes  of  a  gouty  family,  and  her 
brother  is  asthmatical.  She  has  at  various  times  suffered  from  pain  and 
swelling  of  the  joints,  especially  of  the  small  articulations,  several  of  which 
are  defoi-med.  The  urine  is  often  charged  with  brick-red  deposit.  She  suffers 
to  a  small  extent  from  haemorrhoids,  but  her  digestive  functions  are  in  good 
condition.  She  has  repeatedly  had  serious  attacks  of  pulmonary  congestion, 
haemoptysis,  &c.  Tor  some  time  back  the  lungs  have  been  healtliy,  but  the 
uterus  is  affected  with  chronic  congestion,  occurring  apparently  without  cause  ; 
twelve  da^'s  after  the  catamenia  there  is  an  exacerbation  causing  acute  pain  and 
rendering  walking  impossible.     This  state   is  accompanied  by  serious   general 


156         TEEATMENT    OF    UTERINE    DISEASES   IN   GENEEAL 

disorder ;  in  a  few  days  there  is  an  improvement  allowing  the  patient  some 
days'  rest  before  the  return  of  the  monthly  period.  This  is  ushered  in  with 
gi-eat  pain,  a  condition  which  never  existed  previously  ;  after  two  or  three  days 
the  pain  ceases  and  the  haemorrhage  is  more  abundant  than  before  the  uterine 
disease.  I  have  sometimes  known  this  patient  for  five  or  six  months  to  have 
hardly  any  suffering  or  congestion,  and  then  begin  to  suffer  anew.  These 
pains  and  the  morbid  conditions  developed  successively  in  the  limbs,  chest,  and 
uterus,  keep  her  extremely  thin,  and  produce  a  great  tendency  to  perspiration 
and  a  general  weakness  in  spite  of  an  excellent  appetite  and  good  digestion. 
I  do  not  know  whether  I  have  given  a  sufficiently  exact  description  of  this  case 
to  convince  my  readers  that  this  succession  of  morbid  conditions,  so  serious  and 
at  the  same  time  so  variable,  can  only  be  explained  as  attacks  of  visceral  gout, 

I  do  not  think  any  one  can  doubt  as  to  the  influence  of  catarrhal, 
chl orotic,  herpetic  and  scrofulous  affections  on  uterine  diseases. 

7.  Inflammation  dXso  plays  a  great  part  in  the  production  of  uterine 
diseases.  Sometimes  it  constitutes  the  basis  or  even  the  essence  of  the 
disease ;  at  other  times  it  plays  only  a  secondary  role  to  the  diathetic 
affection.  In  the  first  case  the  uterine  disease  may  be  called  re- 
actionary; in  the  second,  as  in  the  case  just  cited,  affective.  Thus,  as 
the  result  of  traumatism  or  of  causes  which  may  be  called  traumatic, 
such  as  sexual  excesses,  fatigue  during  menstruation,  abortion,  difficult 
labours,  operations  performed  on  the  genital  organs,  acute  inflamma- 
tions are  often  developed  which  are,  to  speak  correctly,  reactionary, 
such  as  metritis,  ovaritis,  peritonitis;  these  inflammations  become 
chronic  if  they  are  too  aggravated  to  undergo  natural  resolution,  or 
too  slight  to  terminate  in  suppuration  or  gangrene,  and  the  disease 
retains  the  inflammatory  nature  with  certain  modifications. 

At  other  times  the  disease  has  begun  with  inflammatory  symptoms 
but  is  evidently  kept  up  by  a  diathesis  retaining  nothing  of  an  in- 
flammatory character  but  the  form  or  a  state  of  special  complication. 
Nevertheless,  at  a  given  moment,  under  the  influence  of  unforeseen 
accidental  causes  or  even  of  normal  processes,  such  as  menstruation, 
this  condition  may  produce  an  increase  in  the  inflammatory  element 
which  will  now  occupy  the  first  place  among  the  existing  morbid 
phenomena,  owing  to  the  danger  it  involves.  But  whether  inflamma- 
tion form  the  basis  of  the  uterine  disease  or  be  only  an  element  of 
secondary  importance  subordinate  to  the  diathesis,  or  an  accidental 
coincidence  more  or  less  serious,  it  always  presents  important  indica- 
tions. In  the  one  case  the  leading  indication  is  to  subdue  it,  in  the 
other  this  is  -of  secondary  importance — secondary,  that  is  to  say,  to 
that  of  the  diathesis;  but  in  all  cases  it  deserves  the  most  serious 
consideration. 

8.  Another  important  source  of  indications  is  the  asthenic  nature  of 
the  majority  of  uterine  diseases,  no  matter  what  part  inflammation 
plays  in  them.  If  we  consider  the  condition  of  the  vital  forces,  i.  e. 
the* resistance  which  the  economy  is  capable  of  making  in  this  struggle, 
we  can  assuredly  say  that  generally  there  is  not  a  sufficient  power  of 
resistance.  Occasionally  it  may  exist  in  acute  uterine  disease  and  in 
inflammatory  attacks,  which  give  a  new  character  and  nature  to  the 
disease.  But  generally  the  reverse  holds  good.  As  a  result  of  the 
chronic  state  of  the  malad}',  of  the  sympathetic  disorders  of  digcs^''^*^ 


INDICATIONS   FOE    TEEATMENT  157 

and  innervation,  and  of  the  consequent  impoverishment  of  blood,  there 
is  a  state  of  general  debility  wliich  not  onlj  takes  from  patients  the 
tone  which  gives  energy  and  activity  to  the  whole  system,  but  also 
deprives  them  of  what  the  ancients  called  motor  force.  Besides  the 
atony  with  which  the  muscular  system  and  the  whole  of  the  organism 
is  affected,  we  may  say  that  the  majority  of  uterine  diseases  are 
characterised  by  asthenia.  Therefore,  after  having  subdued  inflamma- 
tion or  congestion  by  blood-letting  or  otherwise  when  necessary,  we 
must  hasten  to  overcome  the  diathesis  which  has  a  share  in  the  disease, 
and  above  all  to  raise  the  strength  by  enriching  the  blood,  soothing 
the  nervous  system,  facilitating  digestion,  stimulating  nutrition,  and 
by  giving  an  impetus  to  the  repairing  processes  in  all  the  organs. 

9.  The  chronicity  of  uterine  diseases  is  also  an  indication  of  con- 
siderable importance.  A  small  number  of  uterine  diseases  have  an 
acute  course.  Such  are  those  diseases  which  may  be  called  trau- 
matic, as  well  as  those  having  a  sthenic  character  and  tending  to 
inflammation,  and  those  consequently  which  participate  in  the  nature 
of  reactionary  affections,  such  as  cases  of  metritis,  ovaritis,  haemato- 
celes  at  their  commencement,  peritonitis,  inflammatory  attacks  of  pelvic 
peritonitis  or  peri-uterine  inflammation,  active  hsemorrhage,  &c.  But 
the  majority,  on  the  contrary,  are  chronic  in  character ;  there  is  some- 
thing slow  in  their  manifestation  and  a  natural  tendency  to  last  indefi- 
nitely. This  chronic  character  depends  on  two  causes :  primarily,  on 
the  influence  of  the  diathesis,  or  at  least  on  the  asthenic  nature  of  the 
malady.  All  diathetic  affections  are  difficult  to  cure.  They  are  deeply 
rooted  in  the  whole  economy ;  the  whole  mass  of  the  tissues  needs  to 
be  gradually  modified,  a  requirement  which  necessitates  a  long  and 
uninterrupted  treatment.  Even  when  a  uterine  disease  cannot  be 
attributed  to  a  diathesis,  its  asthenic  nature  calls  equally  for  reconstitu- 
tion  of  the  blood  and  restoration  of  the  whole  system.  Secondarily, 
it  depends  on  special  causes  peculiar  to  the  uterus,  which  keep  up  the 
disease  by  bringing  obstacles  in  the  way  of  its  cure.  The  womb  is  not 
only  placed  below  all  the  abdominal  viscera,  which  by  their  weight 
tend  to  keep  up  the  congestion  as  well  as  to  cause  pain  mechanically ; 
not  only  is  it  subject  to  the  troublesome  and  repeated  excitement  of 
conjugal  relationship,  but  every  month  it  is  the  seat  of  a  normal  san- 
guineous discharge,  which  to  a  great  extent  undoes  the  good  derived 
from  previous  treatment,  giving  at  the  same  time  new  life  to  the 
disease.  Those  patients  are  fortunate  who  escape  with  only  a  monthly 
periodical  flow,  many  having  a  recurrence  every  fortnight.  These 
periodical  discharges,  besides  tending  to  perpetuate  the  disease  by  the 
accompanying  congestion,  haemorrhage,  pain  and  other  pathological 
conditions,  are  troublesome  from  their  necessitating,  in  the  majority  of 
cases,  an  interruption  to  treatment,  which  delays  cure.  Therefore  we 
must  expect  to  lose  every  month  part  of  the  good  we  have  already 
gained,  and  must  content  ourselves  with  a  very  slow  and  gradual 
improvement. 

As  the  chronicity  of  the  disease  cannot  be  altered,  an  appropriate 
treatment  should  be  adopted,  which  can  be  prolonged  indefinitely. 


158  TEEATMENT    OF    UTERINE    DISEASES    IN    GENERAL 

If  a  suitable  treatment,  local  as  well  as  general^  is  applied,  patients 
soon  obtain  marked  relief.  Leeches,  a  purgative,  baths  and  douches, 
with  tonics,  when  rightly  employed,  seem  to  rid  them  of  all  their  pains 
and  discomforts.  They  think  themselves  cured.  But  the  physician 
must  not  deceive  himself;  the  relief  is  only  temporary.  The  organs 
have  not  sufficient  tone  to  preserve  them  from  a  relapse ;  the  diathesis 
still  exists ;  the  uterine  discharge  will  soon  recur,  forcing  us  to  dis- 
continue treatment,  and  taking  possession  of  the  organ  will  throw  it 
back  into  its  original  condition.  Therefore,  I  repeat,  as  the  disease 
is  chronic  the  treatment  must  be  so  also. 

10.  More  is  needed:  we  must  j)reveni  relapses.  Treatment  must 
be  continued  for  a  considerable  time  after  an  apparent  cure,  even 
after  a  real  cure.  The  causes  of  the  chronicity  of  uterine  diseases  are, 
at  the  same  time,  causes  of  relapse,  and  if  we  would  destroy  their 
power  we  must  give  tone  and  strength  to  the  whole  economy,  and 
especially  to  the  diseased  organs,  in  order  to  preserve  them  from 
relapses. 

11.  T/ie  elementary  nature  and  form  of  the  uterine  disease  is 
another  source  of  indications  which  must  not  be  neglected  in  treat- 
ment. The  various  elements  which  contribute  by  their  union  to  give 
the  disease  its  form,  physiognomy,  and  special  appearance,  may  com- 
bine in  different  ways  or  be  associated  with  such  or  such  a  disease  as 
primary  or  secondary  element.  In  this  way  fluxion,  congestion,  hae- 
morrhage, leucorriioea,  ulceration,  pain,  engorgement,  hypertrophy, 
displacement,  may  be  alternately  principal  or  accessory  elements  of 
the  disease,  and  become  the  source  of  primary  or  secondary  indications. 
Many  of  these  elements  are  not  mere  alterations  of  tissue  or  modifica- 
tions of  local  life,  but  morbid  processes  of  the  whole  economy,  having 
the  uterus  for  their  starting  point  or  goal,  and  passing  for  simple 
affections.  These  affections  may  remain  simple  or  become  compli- 
cated by  several  other  pathological  elements.  This  remark  applies 
especially  to  the  most  common  of  these  elements — -jiiixion.  Whether 
it  be  an  original  element  of  the  disease  or  a  later  complication,  fluxion 
is  the  morbid  process  against  which  we  have  to  struggle  with  most 
persistency  in  the  treatment  of  uterine  disease.  We  have  to  contend 
not  only  with  imminent  or  established  pathological  fluxion,  but  even 
with  the  periodical  physiological  fluxion,  at  least  in  its  derangements, 
and  to  prevent  the  consequence  of  its  baneful  influence  on  the  malady. 
I  cannot  too  strongly  recommend  the  excellent  treatise  of  Bartbez  on 
this  subject  ('  Traitement  Methodique  des  Fluxions^).  The  distinc- 
tion made  between  the  fluxion  that  is  imminent  and  the  one  that  is 
established  is  very  practical.  The  precept  to  use  revulsives  to  prevent 
the  first  from  becoming  fixed  and  to  employ  derivatives  to  arrest  the 
second  is  excellent. 

Congestion  or  vascular  fulness  of  the  organ  is  often  only  an  estab- 
lished fluxion.  It  may  then  be  called  active  congestion,  and  hidicates 
the  necessity  for  revulsives  or  derivatives.  When  it  is  passive  it  is 
none  the  less  an  important  and  frequent  source  of  indication,  which  is 
best  fulfilled  by  depletion. 


INDICATIONS    FOR    TBEAT.MEXT  .  159 

Engorgement,  or  the  presence  of  interstitial  plasma^  which  is  some- 
thing between  oedema,  congestion  and  hypertrophy,  naturally  indicates 
the  use  of  resolvents. 

Hypertrophy,  or  increase  of  the  uterine  tissue  by  excess  of  assimila- 
tion or  defect  of  decomposition,  indicates  reabsorption.  When  this 
hypertrophy  is  localised  on  some  point  of  the  organ  and  some  portion 
of  one  of  the  tissues,  and  has  given  birth  to  granulations,  fungous 
growths,  polypi,  fibromata,  &c.,  it  may  become  the  source  of  special 
indication,  that  of  the  local  destruction  of  abnormal  tissue  by  ablation 
or  otherwise. 

The  discharges  themselves  are  sources  of  therapeutic  indication, 
only  these  are  often  of  minor  importance,  subordinate  to  others  arising 
from  the  morbid  condition,  whether  diathetic  or  otherwise,  on  which 
these  discbarges  depend.  For  example,  fluxion,  congestion,  organic 
alterations,  in  reference  to  heemorrhage ;  catarrh,  chlorosis,  herpes, 
scrofula,  with  respect  to  leucorrhoea,  furnish  indications  to  be  fulfilled 
primarily,  being  of  greater  importance  than  those  even  of  the  hsemor- 
rhage  or  leucorrhcea.  Ulceration  and  the  consequent  more  or  less 
serious  loss  of  substance,  whether  granular  or  fungous,  becomes  in  its 
turn  a  source  of  indication.  Subordinate  as  it  is  to  the  treatment  of 
the  diathesis  on  which  the  ulcer  often  depends,  the  indication  to  bring 
about  cicatrisation  is  not  the  less  urgent. 

Pain  is  one  of  the  most  important  sources  of  indication ;  it  may 
exist  in  the  uterus  or  around  it,  or  sympathetically  in  distant  parts. 
It  may  be  transitory  or  persistent;  it  assumes  difl'erent  forms — hyper- 
esthesia, neurosis,  or  neuralgia — and  may  be  idiopathic,  symptomatic, 
or  sympathetic.  It  must  be  subdued  whenever  it  appears,  for  pain 
increases  the  fluxion  and  all  the  elements  of  the  malady,  and  is  sufh- 
cient  to  bring  them  back  if  we  have  been  fortunate  enough  to  get  rid 
of  them.  We  must  attack  it  at  every  period  of  the  disease,  and  even 
after  its  cure,  for  it  sometimes  persists  after  the  organ  has  returned  to 
a  satisfactory  state  of  health. 

Lastly,  the  position  of  the  uterus,  the  condition  of  its  suspensory 
ligaments,  the  changes  in  its  normal  relationships,  all  become  sources 
of  indications.  Only  we  must  had  out  whether  the  morbid  symptoms 
really  depend  on  the  displacement  or  are  independent  of  it.  When 
the  disease  is  confined  to  a  deviation  or  displacement,  even  then  the 
indication  may  be  complex — 1.  To  prevent  the  abdominal  viscera,  by 
means  of  rest,  attitude  and  supporting  belts,  from  increasing  the  dis- 
placement of  the  organ  and  causing  pain.  2.  To  render  the  displace- 
ment bearable  by  palliative  treatment  or  by  the  use  of  mechanical 
support,  y.  LasUy,  to  obtain  a  radical  cure  by  attacking  directly  the 
causes  of  the  displacement  or  deviation. 

1£.  Special  indications  arise  from  ntighhonring  disorders  accom- 
panying uterine  disease.  The  condition  of  the  urine  ought  to  be 
examined.  In  acute  as  well  as  in  chronic  diseases  we  often  find  this 
excretion  abnormal.  Lithiasis,  concentration,  deposits  of  various 
kinds,  are  all  sources  of  indication,  as  well  as  tenesmus,  inflammation, 
catarrh,  frequent  or  difficult  micturition,  mechanical  compression  of 


160         TREATMENT  OF   UTEBINE    DISEASES    IX  GENEEAL 

the  bladder  or  urethra  by  uterine  tumours,  kc.  Then  we  have  dis- 
orders connected  with  the  rectum,  diarrhoea,  tenesmus,  hsemorrhoids, 
glairy,  mucous  or  bloody  discharges,  and,  above  all,  constipation,  the 
most  common  and  hurtful  of  all  complications,  keeping  up  as  it  does 
pelvic  congestion. 

13.  What  can  be  said  of  the  sympathetic  reaction  of  uterine  diseases 
on  the  nervous  system  and  digestive  economy  but  that  the  consequent 
functional  disorders  are  sources  of  indication  ?  Let  me,  however, 
remark  that  the  majority  of  the  indications  arising  from  these  dis- 
orders are  already  fulfilled  by  the  means  employed  in  combating 
asthenia,  raising  the  tone  of  the  whole  economy,  soothing  pain,  regu- 
lating the  nervous  system,  improving  the  condition  of  the  blood, 
increasing  nutrition,  renewing  the  whole  constitution. 

14.  What  can  be  said  too  of  the  very  serious  complications  which 
sometimes  increase  the  severity  of  uterine  diseases  and  prevent  a  con- 
tinuance of  the  treatment,  but  that  these  complications  are  new 
sources  of  indications  ?  From  the  point  of  view  of  preservation  of 
life  or  of  general  health  they  may  take  precedence  of  those  arising 
from  the  disease  of  the  womb,  they  may  even  oblige  the  physician  to 
respect  the  uterine  disease,  as  a  sort  of  natural  revulsive  guaranteeing 
the  general  health  against  the  rapid  and  disastrous  evolution  of  the 
coexisting  disease.  This  may  be  the  case  where  pulmonary  tubercu- 
losis is  coincident  with  leucorrhoea  or  uterine  ulceration.  It  is  often 
imprudent  to  insist  on  the  cure  of  uterine  diseases  in  phthisical 
patients.  If  it  is  wise,  as  Bennet^  says,  to  modify  uterine  symptoms 
when  they  become  oppressive,  we  must  respect  the  kind  of  equilibrium 
established  between  the  uterine  affection  and  pulmonary  phthisis  when 
the  symptoms  are  bearable ;  all  the  more  so  as  in  these  cases  the  use 
of  energetic  means  is  not  always  without  danger.  We  must  remember 
in  this  case,  as  in  that  also  of  haemorrhoids,  rectal  fistula,  gouty 
deposits  in  the  small  articulations,  &c.,  that  there  are  diseases  which  it 
is  dangerous  to  cure ;^  and  that  the  aphorism  of  Hippocrates^  is 
equally  true  with  reference  to  diseases  as  to  treatment : — "Aug  wovwv 
ajua  yivofxevwv  fii]  Kara  tov   avrov   tottov,  6   (r^ocpoTepog  afiavpoi 

TOV  tTSpOV. 

METHODS    OF   TREATMENT   AND    VARIOUS    MEDICATIONS    IN   UTERINE 

DISEASES. 

Having  enumerated  the  indications,  the  question  arises,  what 
method  should  be  employed  in  the  treatment  of  uterine  diseases,  and 
what  medicatiotis  wiU  suitably  fulfil  the  indications  for  this  treatment  ? 

The  ?nedicatioti  is  the  direct  answer  to  the  indication  :  it  is  an 
impression  produced  on  the  organs  by  a  means  or  the  association  of 
several  means,  and  intended  to  modify  the  economy  in  one  sense  or 

'  Bulletin  general  de  therapeutique,  t.  Ixix,  p.  49.     Paris,  1865. 
^  Raymond  de  Mai-seille,  Traite  des  maladies  qu'il  est  dangereiuc  de  guerir. 
Paris,  1816. 

^  Section  2,  aphorism,  46. 


METHODS    OF    TREATMENT    AND    MEDICATIONS  161 

another.  The  method  is  the  order  to  be  followed  in  the  use  of  the 
medications,  and  of  the  means  by  which  they  are  carried  out :  it  is 
simply  a  help  which  we  give  nature  when  she  tends  towards  cure;  or 
a  way  indicated  to  her,  an  impulse  given  to  her  from  different  points 
all  directed  to  one  end;  or  a  rule  imposed  on  her  without  apparent 
reason,  but  which  experience  has  proved  to  be  wise. 

Methods  of  treatment  according  to  Barthez  ^  may  be  divided  into 
natural,  analytical,  and  empirical.  It  is  needless  to  say  that  we  can 
seldom  in  the  treatment  of  uterine  maladies  limit  ourselves  to  natural 
methods,  because  these  diseases  rarely  have  any  tendency  to  sponta- 
neous cure.  On  the  contrary^  we  must  often  have  recourse  to  analy- 
tical methods  ;  for  these  diseases  are  usually  the  product  of  one  or 
more  elements  of  one  or  more  essential  affections,  and  of  several 
simpler  diseases  existing  as  complications.  They  are  almost  always 
complex ;  at  least  they  are  complicated  with  all  the  morbid  conditions 
consequent  on  the  special  structure  and  functions  of  the  womb. 
Therefore  we  must  simultaneously  treat  the  diathetic  affection,  which 
often  gives  to  the  disease  its  character,  and  the  morbid  processes  which 
give  to  it  its  form  or  which  determine  its  exacerbations,  its  relapses 
and  its  chronic  nature,  or  sometimes  the  simple  disorders  of  men- 
struation which  keep  it  up  or  increase  it.  In  this  way  inflammation, 
engorgement,  hypertrophy,  granulations,  ulcers,  necessitate  the  use  of 
certain  means,  at  the  same  time  that  the  diathesis  is  treated  by  an 
appropriate  medication.  Haemorrhage,  congestion,  simple  fluxion  are 
treated  as  they  arise  according  to  their  relative  importance ;  e.g.  if 
fluxion  is  defective,  the  use  of  attractives  is  indicated  ;  if  excessive, 
then  depletion  or  derivatives  are  indicated.  Lastly,  we  must  some- 
times have  recourse  to  empirical  methods  ;  for  the  disease,  even  when 
capable  of  being  analysed,  may  resist  the  ordinary  means  of  treatment, 
showing  no  tendency  to  be  cured,  or  it  may  be  kept  up  by  a  specific 
affection  the  cure  of  which  can  only  be  effected  by  a  specific  medicine 
which  experience  has  pr'oved  to  be  efficacious.  This  happens  in  many 
chronic  diseases,  especially  when  neuroses  or  local  indolent  engorge'- 
ment  predominate  ;  in  such  a  case  an  acute  attack  may  bring  about  a 
change  which  may  become  the  starting-point  of  a  favorable  impetus 
towards  cure. 

Medications. — The  methods  of  treatment  suitable  to  uterine  diseases 
having  been  determined,  we  must  carry  out  the  treatment  in  the  order 
indicated  by  the  use  of  the  general  and  local  means  at  our  dis- 
posal. Here  also  we  find  a  medium  between  the  method  and  treat- 
ment. Every  means  of  treatment  produces  several  results,  some- 
times the  one,  sometimes  the  other,  successively  or  simultaneously; 
on  the  other  hand,  the  association  of  several  means  may  be  necessary 
to  produce  a  single  impression  on  the  economy,  just  as  the  concur- 
rence of  several  processes  is  necessary  to  accomplish  a  single  function. 
The  means  therefore  cannot  be  applied  directly  without  an  inter- 
mediary in  answer  to  the  indication. 

'  Preface  du  Traite  des  maladies  goutteuses,  1819  ;  V.,  Nouveaux  Mements 
de  la  science  de  I'homme,  &c.,  3',  ed.,  t.  ii,  p.  282.     Paris,  1858. 

11 


162         TREATMENT    OF    UTEEINE    DISEASES   IN   GENERAL 

The   association  of  various  general   and   local   means   constitutes 
a  medication  :  and  it  is  by  the  help  of  medications  that  we  respond 
to  the  indications.       The  true  answer  to   the  indication  is  not  the 
medicine  but  the  medication  or  medications.     One  or  several  medica- 
tions answer  to  one  or  several  indications.     Sometimes  a  single  medi- 
cation suffices  for  one  indication^  but  it  may  include  several  medicines 
or  kinds  of  medicines.     Sometimes  two  or  more  medications  must  be 
associated  to  respond  successively  or  simultaneously  to  two   or  more 
indications.     The  distinction  is  so  essential  between  medicines,  i.  e. 
the  means  and  methods  of  treatment,  and  medications,  i.  e.  the  manner 
of  responding  to  an  indication  by  the  effect  which  such  remedies  pro- 
duce, that  it  is  as  impossible  to  group  these  medicines  by  medications  as 
by  indications.     The  combination  of  several  means  is  necessary  for  one 
medication,  and^  on  the  other  hand,  the  same  means  may  serve  in  several 
medications  or  may  carry  out  several  indications  at   the  same  time. 
Bleeding,  for  example,  is  a  depletive,  derivative,  revulsive,  debilitant ; 
purgatives   are  not   only  evacuants,  they  are   derivatives,  revulsives, 
resolvents  ;    hydropathy  is  at  the  same  time  sedative,  tonic  and  revul- 
sive ;  vaginal  irrigation  may  be  refrigerant,  sedative,  astringent,  &c. 
The  same  medication  makes  use  of  various  means   according  to  the 
case ;  thus,  resolvent  medication  utilises  evacuants,  revulsives,  altera- 
tives, hydropathy,  starvation,  &c. ;  the  choice  depends  on  the  patients, 
on  the  disease,  on  the  constitution,  on  the  remedies  at  our  disposal. 
We  must  therefore  postpone  reviewing  the  means  to  be  employed  in 
the  treatment  of  uterine  diseases,  contenting  ourselves  with  grouping 
them  according  to  their  natural  affinities.     As  for  the   medications, 
they  are    arranged  naturally  like  the  indications  to  which  they  are 
intended  to  respond.     When  I  set  out  in  quest  of  the  indications  I 
simply  followed  the  order  we  adopt  in  practice  to  discover  them  and 
to  determine  the  disease,  and  by  enumerating  successively  their  different 
sources  I  showed  how  they  arise.     But  the  indications,  when  once 
found,  ought  to  arrange  themselves  in  our  mind  according  to  their 
various    degrees    of  importance,  according    as  they   are    common    or 
special,   local  or   general,   major   or   minor,   primary   or    accessory. 
The  medications  respond  so  directly  to  them  with  regard  to  the  cura- 
tive effects  which  we  hope  to  obtain  from  them,  that  we  cannot  but 
arrange  them  in  this   essentially  therapeutical  order.     There  is   the 
same  difference  between  the  order  in  which  the  indications  present 
themselves  and  that  in  which  the  medications  appear,  as  between  the 
way  of  making  a  diagnosis  and  that  of  instituting  a  treatment.     There- 
fore I  distinguish  between  common  and  special  medications. 

Common  medications  are  those  which  respond  to  common  indica- 
tions, i.  e.  indications  which  may  arise  in  every  uterine  disease.  I 
have  already  said  that  the  various  processes  which  go  to  make  up  men- 
struation are  almost  invariably  sources  of  indication  in  uterine  patho- 
logy. By  their  simple  presence,  by  their  absence,  excess,  derangement, 
by  the  pains  accompanying  them,  they  may  of  themselves  constitute 
morbid  states,  and  in  the  majority  of  cases  be  added  to  the  disease  as 
cause,  effect,  or  complication;   or  they  may  hinder  the  treatment  or 


METHODS    OF   TEEATMENT   AND    MEDICATIONS  163 

retard  the  cure  indefinitely.  "We  must  be  able  to  increase  or  diminish 
the  flow,  dissipate  the  congestion,  relieve  the  vascular  system,  or 
deviate  the  blood  which  flows  towards  the  organ  by  directing  it  to- 
wards a  distant  organ.  To  each  of  these  indications  there  is  a  corres- 
ponding medication,  attractive,  depletive  or  evacuant,  derivative, 
revulsive.  Sometimes  we  wish  to  attract  the  sanguineous  flow  to- 
wards the  uterus  by  the  help  of  rubefacients,  vesicants,  leeches  to  the 
labia,  groin,  anus,  or  cervix ,  by  hot,  aromatic,  or  mustard  foot-baths 
or  sitz-baths,  by  stimulating  purgatives,  enemata,  or  suppositories, 
by  hydropathy,  electricity,  &c.  At  other  times  we  empty  the  uterine 
vascular  system  by  leeches  to  the  cervix,  scarification,  cupping,  pur- 
gatives, &c.  Sometimes  in  cases  of  fluxion  and  congestion  we  deviate, 
i.  e.  derive  the  blood,  by  applying  leeches  or  blisters  to  the  groins, 
hypogastrium,  or  loins,  or  we  may  cup.  Sometimes  we  turn  away  or 
divert  this  current  and  the  movement  which  produces  it  by  blood- 
letting from  the  arm,  cupping  the  breasts,  administering  a  purgative,  or 
even  an  emetic,  or  by  directing  the  fluxion  to  the  surface  of  the  whole 
body  by  means  of  vapour  baths  and  other  hydropathic  operations,  &c. 
I  will  explain  afterwards  that  it  is  not  enough  to  be  able  to  use  these 
medications ;  we  must  learn  how  to  apply  them  opportunely. 

Special  medications  correspond  to  indications  which  do  not  occur 
in  every  case,  but  which  vary  according  to  the  nature  of  the  afl'ection, 
the  pathological  form  assumed,  and  the  organic  alteration  produced  by 
it.  Some  are  local.  Por  example,  medication  consisting  of  appli- 
ances which  are  reducing  and  supporting,  for  the  treatment  of  dis- 
placements, deviations,  &c. ;  atrophic  or  hypertrophic  in  cases  of 
uterine  hypertrophy  or  atrophy;  substitutive  and  modificatory  in 
cases  of  superficial  alterations  of  vitality  and  fluxion,  of  granula- 
tions or  ulcers;  destructive  by  the  knife,  caustics  or  fire,  in  cases 
of  more  profound  organic  alterations,  or  considerable  tumefaction,  or 
formation  of  new  elements  and  of  homeomorphous  or  heteromor- 
phous  tumours.  Other  medications  are  general,  or  both  general  and 
local :  antiphlogistic,  directed  against  inflammation,  no  matter  where 
the  seat  or  what  the  extent  may  be  ;  resolvent,  with  which  the  atrophic 
medication  is  often  associated,  against  engorgement  or  other  causes 
of  permanent  increase  of  volume ;  anti-diathetic,  whether  simply  altera- 
tive or  specific,  against  general  aff'ections,  the  localisation  of  which 
keeps  up  the  morbid  state ;  sedative  and  narcotic,  against  pain, 
whether  it  be  an  essential  element  or  a  complication;  antispasmodic, 
against  spasm  and  nervous  erethism;  tonic,  against  weakness,  want  of 
tone,  and  strength  ;  restorative,  against  digestive  troubles,  disorders  of 
nutrition,  impoverishment  of  blood,  chlorosis,  &c. 

Opportuneness  of  treatment. — This  is  another  great  principle  in 
general  therapeutics,  which  is  specially  applicable  to  uterine  diseases. 
A  brief  explanation  of  it  will  form  the  natural  connecting  link  between 
the  enumeration  which  I  have  just  made  of  the  principal  medications 
used  in  uterine  therapeutics  and  that  which  I  am  about  to  five  of  th 


&' 


16 


means  by  which  we  realise  these  medications.     In  the  cure  of  uterine 
diseases,  next  to  precision  of  diagnosis,  opportuneness  of  treatment 


164  TREATMENT    OF    UTEEINE    DISEASES    IN    GENEEAL 

is  the  best  guarantee  of  success.  The  treatment,  medication  and 
means  must  all  be  employed  at  the  right  moment.  Treatment  may  be 
useless  in  a  few  cases,  indispensable  in  almost  all^  but  hurtful  at  one 
time,  beneficial  at  another.  It  is  the  same  with  medication  and  the 
means  employed.  Very  often  the  same  end  may  be  reached  by 
several  medications,  the  same  medication  by  several  medicines  and 
means ;  in  short,  there  are  different  ways  of  treating  a  patient.  There 
is  opportuneness  with  regard  to  the  disease,  the  medication  and  the 
means,  but  especially  with  regard  to  the  patient ;  for  the  various 
parts  of  the  economy  are  not  in  a  good  condition,  the  constitution  is 
often  enfeebled,  the  blood  impoverished,  the  nervous  system  affected, 
all  the  functions  languid. 

I  cannot  too  carefully  impress  on  my  readers  the  necessity  of  exam- 
ining all  the  organs  attentively.  It  is  not  enough  to  examine  a  patient 
for  purposes  of  diagnosis;  we  must  also  examine  with  reference  to 
treatment.     By  carefully  investigating  the  various  functions,  systems 
and  organs,  we  sometimes  had  disorder  where  we  least  expected  it.   But 
that  is  not  all.     In  treating  disease  it  is  necessary  to  make  an  impres- 
sion on  certain  organs  by  means  of  medicines.  Only  there  are  different 
ways  of  producing  this  impression,  different  means  of  arriving  at  the 
same  end.     True  art  consists  in  being  able  to  choose  the  best,  the  one 
most  appropriate  not  only  to  the  disease,  but  to  the  patient.     That  is 
why  we  must  interrogate  every  function,  examine  every  organ  to  learn 
if  we  can  and  should  act  on  the  stomach,  the  intestines,  the  kidneys, 
the  skin,  &c.     How  often  after  having  made  a  careful  examination  do 
we  find  another  disease  counter-indicating  treatment !     How    often 
do  we  find  the  condition  of  certain  organs  such  that  treatment  would 
do  more  harm  than  the  disease  !    Supposing,  however,  that  the  patient 
bears  the  treatment,  and  that  it  is  applied  at  the  right  time,  it  is  not 
enough  unless  the  medication  and  the  means  are  used  opportunely.    It 
is  of  more  importance  to  be  able  to  seize  the  opportune  moment  in 
treating  uterine  than  other  diseases.     The  recurrence  of  menstruation 
introduces  such  important  changes  into  the  condition  of  the  organ, 
that  we  must  not  only  suspend  the  usual  treatment  during  the  whole 
of  the  monthly  period,  but  we  must  utilise  this  time  by  employing  new 
means,  which  are  only  efficacious  when  used  at  the  right  moment.     I 
have  seen  many  patients  who  had  undergone  treatment  which  they 
assured  me  had  aggravated  their  disease,  and  yet  the  very  same  means 
were  most  successful  when  used  by  me  at  an  opportune  time. 

Let  us  take  an  example.  One  of  the  means  which  gives  the  most 
marked  and  rapid  relief  in  the  treatment  of  uterine  disease  is  the  appli- 
cation of  leeches  to  the  cervix.  Struck  by  my  success,  all  my  pupils 
have  adopted  this  practice ;  but  sometimes  I  have  been  called  on  to 
rectify  their  error,  and  to  repair  the  troublesome  consequences  of 
treatment  clearly  enough  indicated,  but  inopportunely  or  insufficiently 
carried  out.  This  practice,  though  less  frequently  adopted  than  it 
deserves  to  be,  is  yet  common  enough  to  have  allowed  me  to  see  a 
certain  number  of  patients  from  different  parts  of  Europe  who  had 
undergone  this  little  operation  in  their  own  country.     With  several  I 


METHODS    OF    TREATMENT    AND   MEDICATIONS  165 

have  been  obliged  to  have  recourse  again  to  the  same  means,  and 
sometimes  have  had  considerable  difficulty  in  overcoming  the  opposi- 
tion of  my  patients,  who  remembered  that  a  previous  application  had 
increased  their  pain  and  all  other  symptoms,  and  had  even  developed 
new  troubles.  It  is  very  easy  to  explain  these  differences,  and  I  have 
laid  down  rules  calculated,  I  hope,  to  prevent  accidents  resulting  from 
an  inopportune  application  of  leeches,  whilst  retaining  so  valuable  an 
agent  in  uterine  therapeutics.  Leeches  may  be  applied  to  the  cervix 
during  any  part  of  the  intermenstrual  period,  with  the  exception  of  the 
last  week,  provided  they  draw  a  sufficient  quantity  of  blood.  If  not, 
they  must  be  applied  again  and  again  if  necessary,  because  after  an 
insufficient  flow  of  blood  we  always  see  an  aggravation  of  symptoms, 
especially  of  pain.  The  reason  is  this : — The  suction  of  the  leeches 
has  determined  a  flow  of  blood  towards  the  organ  which  has  not  been 
evacuated.  The  vascular  system  is  more  gorged  than  before,  hence 
the  marked  aggravation  of  all  the  symptoms  and  of  the  disease  itself. 
The  only  remedy  is  to  make  a  fresh  application  of  leeches,  and  if  re^ 
quisite  another,  till  an  abundant  hsemorrhage  has  caused  depletion  of 
the  blood-vessels.  Leeching  the  cervix  during  the  week  preceding 
menstruation  may  be  indicated  by  the  absence  or  insufficiency  of  the 
fluxionary  movement  accompanying  the  recurrence  of  the  monthly 
period.  In  this  case  it  acts  as  an  attractive  inducing  fluxion  towards 
the  uterus.  As  this  indication,  however,  generally  occurs  in  young 
girls,  and  as  it  can  be  responded  to  almost  as  well  by  leeching  the 
groins  or  the  labia,  this  latter  operation  should  be  preferred.  If,  how- 
ever, we  have  to  do  with  another  disease,  metritis  for  example,  or 
uterine  congestion,  for  which  the  application  of  leeches  to  the  cervix 
is  clearly  indicated  (as  a  depletive,  not  as  an  attractive),  we  must 
beware  of  making  the  application  during  the  days  which  precede  men- 
struation^  especially  if  we  have  to  do  with  a  hsemorrhagic  congestion. 
The  flow  of  blood  towards  the  uterus  commences  a  few  days  before  the 
periodical  discharge  takes  place.  The  organ,  under  the  influence  of 
this  continuous  fluxion,  becomes  gradually  congested,  and  this  con- 
gestion produces  disease  if  the  natural  haemorrhage,  which  is  the  crisis 
and  the  third  act  of  this  morbid  drama,  does  not  arrive  in  time  or  is 
insufficient.  If,  then,  the  organ  is  suffering  from  simple  congestion  or 
an  inflammatory  condition  or  is  the  seat  of  haemorrhages  which,  in 
place  of  relieving,  add  to  the  morbid  condition,  it  is  evident  that  the 
application  of  leeches  will  only  increase  pre-menstrual  congestion  and 
consequently  all  the  accidents  produced  by  the  pathological  congestion 
or  inflammation.  The  natural  congestion  preparatory  to  menstruation 
is  of  itself  a  troublesome  occurrence,  and  we  know  that  in  the  majority 
of  uterine  diseases  the  return  of  the  monthly  period  is  coincident  with 
the  return  and  aggravation  of  all  the  princi|)al  accidents.  What  then 
will  happen  if  this  natural  congestion  is  increased  by  the  application 
of  leeches,  which  will  add  to  the  usual  afflux  of  blood  preceding  men- 
struation ?  Even  if  the  flow  of  blood  were  to  be  abundant  it  would 
not  prevent  the  pre-menstrual  congestion  from  being  increased  and  all 
the  symptoms  from  being  aggravated,  because  it  would  come  too  soon 


166         TEEATMENT   OP    UTERINE    DISEASES   IN   GENERAL 

to  be  the  crisis^  and  would  not  prevent  menstruation  from  taking  place 
at  the  usual  time,  within  a  few  days  of  the  application  of  leeches ;  nor 
could  it  prevent  the  manifestation  of  all  the  usual  symptoms,  intensified 
in  consequence  of  the  attraction  which  has  been  followed  by  insufficient 
or  useless  depletion. 

These  theoretical  explanations  are  only  the  deduction  of  facts 
learned  by  observation,  for  I  have  seen  serious  accidents  produced  by 
inopportune  leeching.  Therefore,  as  a  general  rule,  the  cervix  ought 
not  to  be  leeched  in  the  week  preceding  menstruation. 

In  the  week  following  menstruation,  on  the  contrary,  the  conditions 
are  quite  different.  The  organ  remains  congested,  especially  if  the 
critical  haemorrhage  has  been  insufficient ;  but  the  fluxion  which  has 
preceded  the  hsemorrhage  and  determined  the  natural  congestion  has 
been  extinct  for  some  days.  Any  depletion  at  that  time  will  be 
beneficial  to  the  uterus.  The  suction  of  the  leeches  will  not  reawaken 
the  fluxionary  movement  which  has  just  ceased,  and  which  will  only  be 
reproduced  normally  in  a  month.  We  can,  therefore,  without  fear 
apply  leeches  to  the  cervix  at  this  time.  If  the  flow  of  blood  is  in- 
sufiicient  it  will  not  be  followed  on  that  account  by  any  accident :  the 
organ  will  be  soothed,  though  incompletely.  If,  on  the  contrary,  it  is 
abundant  and  capable  of  causing  disgorgement  of  the  vessels  of  the 
uterine  system,  the  amelioration  will  be  as  complete  as  rapid,  and  the 
effect  produced  will  sometimes  exceed  all  our  expectations.  To  obtain 
this  result  we  must  not  fear  to  apply  leeches  again  the  following  day 
if  the  first  application  has  been  insufficientj  and  to  follow  it  up  by 
purgatives,  which  are  often  found  to  be  the  necessary  complement  to 
this  method  of  depletion.  Practice  is  rewarded  by  a  success  exceeding 
the  anticipations  of  theory.  Therefore,  as  a  general  rule,  the  cervix 
should  be  leeched  the  day  following  menstruation,  or  at  latest  during 
the  week  following  it. 

What  I  have  said  as  to  the  opportune  application  of  leeches  could 
be  said  with  regard  to  other  means — douches,  sitz-baths,  irrigations, 
purgatives,  ergot,  &c.  But  no  example  seemed  to  me  so  striking  as 
that  of  leeches,  and  I  have  so  often  seen  the  difference  in  the  effects 
produced  by  their  application  at  different  periods,  that  I  cannot  have 
a  doubt  as  to  the  importance  of  the  time  chosen  to  make  use  of  this 
and  other  means. 


MEANS    OF   FULFILLING   INDICATIONS    IN    THE    TREATMENT    OF 
UTERINE    DISEASES 

It  is  not  enough  to  state  the  general  way  of  preparing  and  admin- 
istering these  means,  the  modus  faciendi ;  we  must  also  determine  the 
manner  and  the  time  of  employing  each  one  of  them  under  given 
circumstances  in  order  to  realise  the  medication  indicated.  It  is  the 
only  way  of  successfully  applying  to  other  cases  the  means  which  have 
answered  in  any  given  case.  To  know  why  these  means  have  suc- 
ceeded, is  to  know  what  medication  they  have  realised  and  to  what 


METHODS    OF  TREATMENT  AND  MEDICATIONS  167 

indication  this  medication  has  responded.     The  means  of  fulfilling  the 
indications  are  general  and  local. 

I.   General  Means 

The  general  means  are  hygienic  or  medicinal. 

1.  The  hygienic  means  are  :  posture,  rest  or  exercise,  regimen^  &c. 

Itest  is  often  indispensable.  The  postwe  that  ought  to  be  adopted 
by  the  patient  is  generally  neglected  unless  the  physician  makes  it  his 
business  to  give  precise  instructions  with  regard  to  this  important 
though  small  detail^  and  sees  that  they  are  attended  to.  In  serious 
cases,  always  in  acute  and  often  in  chronic  diseases,  the  patient  ought 
to  remain  in  bed.  She  should  lie  horizontally,  the  pelvis  on  a  level 
with  the  shoulders  or  higher,  the  head  resting  on  a  pillow,  the  legs 
and  thighs  flexed  and  supported  by  pillows  under  the  thighs  ;  in  short 
the  muscles  relaxed  by  semiflexion.  The  bed  ought  to  be  hard  so  that 
the  pelvis  does  not  sink  in  it;  if  the  mattress  is  not  of  hair  it  is  well  to 
put  a  hair  pillow  under  the  pelvis.  Spring  mattresses  combine  resist- 
ance with  elasticity.     Feather  beds  must  be  forbidden  absolutely. 

This  prescription  is  indispensable,  not  only  in  acute  diseases  when 
the  patient  feels  the  necessity  of  rest  and  semi-flexion,  but  in  all  cases 
of  haemorrhage  whether  occurring  at  the  menstrual  period  or  not,  and 
in  several  chronic  maladies,  especially  where  there  is  a  risk  of  hsemor- 
rhage,  as  in  polypi,  fibromata,  &c. ;  or  in  inflammatory  cases,  as  in 
ovaritis,  metritis,  &c.,  absolute  rest  in  the  position  of  semi-flexion  and 
on  the  back,  are  often  the  most  important  elements  of  success.  In 
certain  cases^  e.ff.  retroflexion,  the  contrary  position,  i.e.  pronation, 
must  be  prescribed. 

When  the  disease  is  chronic,  it  is  not  generally  necessary  to  confine 
the  patient  to  bed.  She  may  be  on  the  sofa  during  the  day  if  she 
takes  care  (when  necessary)  to  keep  in  the  position  1  have  just  indi- 
cated. In  spite  of  the  great  importance  which  I  attach  to  rest,  I  do 
not  agree  with  Lisfranc  and  his  school,  in  thinking  it  ought  to  be 
invariably  prescribed  in  chronic  diseases.  Absolute  rest  for  any 
length  of  time,  especially  in  bed,  is  weakening  and  leads  to  loss  of 
appetite  and  impoverishment  of  blood  which  play  so  important  a  part 
in  the  existence  of  uterine  disease. 

We  must  therefore  recommend  exercise  in  these  cases ;  but  the 
exercise  must  be  moderate,  in  proportion  to  the  strength  of  the 
patient,  and  of  a  kind  not  likely  to  excite  pain.  Therefore  we  must 
sometimes  content  ourselves  with  carriage  exercise  on  a  smooth  flat 
road,  making  the  horses  if  necessary  walk,  the  patient  lying  in  the 
carriage  and  being  protected  from  shaking  by  air-cushions.  When 
the  patient  can  take  active  exercise  without  suffering  it  is  much 
better;  in  such  cases  she  should  be  advised  to  walk,  taking  the  pre- 
caution to  choose  a  smooth  road  and  stopping  as  soon  as  she  feels  any 
pain.  She  should  gradually  increase  the  length  of  her  walks,  but  it  is 
better  to  take  several  short  ones  than  one  that  is  too  long,  and  she 
ought  to  lie  down  immediately  afterwards.  A  hypogastric  belt  is 
often  of  great  use  by  supporting  the  weight  of  the  abdominal  viscera 


168        TEEATMENT  OF    UTEEINE   DISEASES    IN    GENERAL 

and  so  preventing  pain  when  walking  or  standing.  Sitting  is  some- 
times very  injurious,  as  it  has  a  tendency  to  cause  pelvic  congestion. 
When  patients  are  obliged  to  sit,  they  ought  to  choose  a  hard  seat  or 
an  air  or  water  cushion,  which  should  be  flat.  Those  which  are 
excavated  in  the  centre  are  injurious  to  women  suffering  from  uterine 
diseases  or  from  hsemorrhoids.  They  spare  the  patient  the  pain 
caused  by  direct  pressure  on  the  hsemorrhoids  or  on  the  uterus ;  but 
they  congest  the  anus  and  lower  part  of  the  rectum,  by  the  circular 
pressure  exercised  on  the  seat. 

The  physician  ought  to  prescribe  the  physiological  rest  of  the  organ 
in  addition  to  the  mechanical  rest.  This  rest  is  indispensable  not  only 
in  acute  cases  but  in  the  great  majority  of  other  diseases.  Engorge- 
ments, deviations,  prolapsus,  do  not  always  counter-indicate  sexual 
intercourse.  But  whenever  there  is  pain  or  fluxion,  inflammation, 
haemorrhage,  or  a  great  tendency  to  the  recurrence  of  any  one  of  these 
morbid  elements,  coitus  must  be  absolutely  forbidden,  and  the  patient 
advised  not  to  share  her  husband^s  room.  This  rule  cannot  be  too 
strictly  enforced  ;  unfortunately,  it  is  too  often  infringed  as  relapses 
testify.  It  is  often  difBcult  to  get  our  instructions  carried  out  by  the 
poorer  classes  ;  indeed,  they  are  not  always  attended  to  by  the  rich. 
In  such  cases  it  is  well  to  advise  patients  of  the  former  class  to  go  to 
a  hospital,  and  those  of  the  latter  to  go  to  a  hydropathic  estabhsh- 
ment  or  to  mineral  waters  when  expedient,  with  the  double  object  in 
view  of  undergoing  treatment  and  of  being  separated  from  their 
husbands.  When  there  is  only  engorgement,  congestion,  or  general 
symptoms  without  local  inflammation  and  a  long  time  is  required  to 
complete  the  cure,  intercourse  ought  to  be  allowed  at  distant  intervals, 
for  there  are  patients  of  a  passionate  nature  for  whom  it  is  necessary. 
Only  I  advise  them,  as  I  advise  men  affected  by  diseases  of  the  pros- 
tate, to  accomplish  the  act  quickly.  Unsatisfied  erotic  desires  which 
keep  up  a  fluxion,  a  nervous  excitement,  a  persistent  orgasm,  are 
infinitely  more  injurious  than  coitus  when  quickly  performed.  It  is 
therefore  better  in  some  cases  to  submit  to  the  inconveniences  of  con- 
jugal relationship  than  to  enforce  abstinence ;  but  it  must  be  on  con- 
dition that  the  patient  is  spared  the  fatigue  of  a  prolonged  state  of 
erethism. 

Coitus  may  have  to  be  forbidden  for  another  reason  :  in  order  to 
avoid  the  possibility  of  pregnancy,  which  occasionally  though  rarely 
occurs  before  a  cure  has  been  obtained.  If  the  physician  considers 
that  pregnancy  will  have  an  unfavorable  influence  on  his  patient  he 
has  no  other  course  to  take. 

The  regimen  in  acute  uterine  diseases  is  the  same  as  in  all  acute 
diseases.  In  chronic  uterine  diseases,  atony,  impoverishment  of  blood, 
debility  of  constitution,  indicate  the  necessity  of  tonics  and  restora- 
tives. The  best  tonic  is  a  good  regimen;  the  best  restorative 
generous  diet.  We  must  therefore  prescribe  roast  meat,  green  veget- 
ables, ripe  fruit,  wine,  &c.  Parinaceous  food  must  be  forbidden,  but 
green  vegetables  and  fruit  allowed  to  prevent  constipation.  When 
the  state  of  the  digestive  functions  will  not  allow  the  use  of  beef  and 


METHODS    OF  TREATMENT    AND    MEDICATIONS  169 

mutton,  we  must  content  ourselves  with  white  meat,  chocolate  and 
milk.  I  often  prescribe  partial  milk  diet  to  patients  whose  digestive 
mucous  membrane  is  in  an  irritable  state  :  in  such  cases  the  milk 
should  be  drunk  warm  and  taken  from  the  same  cow  or  goat,  which 
ought  to  get  from  half  an  ounce  to  an  ounce  of  salt  or  iodide  of 
potassium  daily.  If  there  is  difficulty  in  digesting  the  milk  it  may  be 
mixed  with  lime  water  or  a  little  Vichy  water  or  soda-water.  Milk 
and  water  in  equal  proportions  answers  as  a  laxative  with  some 
women.  There  are  various  ways  of  improving  the  appetite  and  diges- 
tion, preventing  constipation,  &c.,  without  having  recourse  to  medi- 
cines, to  which  I  will  afterwards  refer  when  treating  of  tonics  and 
restoratives. 

We  must  also  pay  attention  to  the  clothing,  dwelling  and  climate. 
It  is  often  desirable  that  flannel  should  be  worn  next  the  skin.  Resi- 
dence in  a  dry  warm  cKmate  is  very  beneficial,  especially  to  patients 
who  are  accustomed  to  a  damp  cold  climate.  According  to  Donne,^ 
M'ho  lived  long  enough  in  Montpellier  to  be  able  to  judge  of  the 
climate,  it  is  superior  to  any  other  town  in  France.  I  have  seen  a 
considerable  number  of  women  affected  by  uterine  diseases  cured  there, 
who  had  been  treated  unsuccessfully  elsewhere  by  physicians  of  high 
reputation.  I  have  often  observed  that  the  same  means  which  had 
been  used  in  other  latitudes  without  any  beneficial  results  produced  a 
decided  improvement  after  a  few  weeks'  trial  in  Montpellier,  and  very 
seldom  more  than  one  winter  is  required  to  effect  a  cure. 

II.  Tlie  medicinal  means  are  :  bleeding,  purgatives,  hydropathy 
(including  mineral  waters,  baths  of  all  kinds,  with  injections),  resolvents, 
tonics  and  restoratives,  sedatives  and  irritants. 

1.  Bleeding  may  be  practised  by  different  methods — by  the  lancet, 
by  leeching,  cupping  or  by  scarification.  It  is  depletive,  derivative 
or  revulsive.  General  bleeding  has  been  recommended  by  Lisfranc  and 
his  school.  Nonat  still  has  recourse  to  this  method  frequently.  It 
is  usually  practised  in  the  arm.  Sometimes  a  considerable  quantity  of 
blood  is  drawn — from  eight  to  ten  ounces — so  that  the  operation  may 
have  a  depletive  effect  on  the  whole  system.  It  is  in  such  cases  said 
to  be  spoliative  ;  but  more  frequently  a  much  less  quantity  is  drawn — 
five  to  six  ounces  ;  it  is  then  said  to  be  revulsive.  It  is  practised 
immediately  before  menstruation  to  diminish  the  flow  of  blood  towards 
the  uterus,  or  during  menstruation  or  immediately  afterwards,  to  divert 
the  flow  in  another  direction.  As  a  rule,  I  consider  spoliative  bleeding 
as  counter-indicated  ;  if  it  has  the  advantage  of  increasing  absorption  it 
has  the  serious  drawback  of  weakening  the  patient.  On  the  other 
hand,  bleeding  from  the  arm  as  a  revulsive  may  be  of  great  use  in  cases 
of  metrorrhagia,  but  especially  in  active  menorrhagia;  also  in  cases  of 
imminent  or  acute  fluxion,  or  fluxion  of  long  standing  previously  set 
in  motion  by  other  means ;  or  of  amenorrhcea,  of  vicarious  menstrua- 
tion with  consequent  congestion  of  other  organs,  such  as  the  lungs. 
It  is  very  seldom  that  bleeding  from  the  foot  is  indicated.     This  little 

^  Gonseils  aux,  families  sur  la  nianicre  d'elever  les  enfants,  p.  300.  Paris, 
1864. 


170        TREATMENT    OF    UTERINE    DISEASES    IN    GENERAL 

operation  only  increases  fluxion  towards  the  uterus.  It  may,  how- 
ever, be  indicated  in  cases  of  amenorrhoea  with  disordered  menstrua- 
tion, when  the  fluxionary  movement  is  directed  towards  the  head  or 
the  chest.  As  an  attractive  it  may  be  resorted  to  in  place  of  leeching 
the  uterus  or  vulva.  It  may  even  act  as  a  derivative  of  fluxion 
localised  on  the  uterus  and  previously  diverted  by  local  depletion. 
This  is,  perhaps,  the  only  case  when  it  is  indicated  in  uterine  diseases. 
Leeching  and  cupping  are,  on  the  contrary,  often  indicated.  They  may 
be  applied  round  the  pelvis  or  close  to  the  uterus,  or  to  the  cervix 
itself.  In  the  case  of  girls  suflering  from  amenorrhcea,  or  when  men- 
struation has  been  suddenly  suppressed  by  some  physical  or  moral 
excitement,  they  may  be  applied  to  the  upper  part  of  the  thighs,  to  the 
groins  or  to  the  labia.  In  this  way  fluxion  is  directed  towards  these 
points  and  to  the  uterus,  whose  vascular  system  is  in  direct  communica- 
tion with  that  of  those  regions ;  they  play  the  part  of  a  direct  and 
powerful  attractive  to  the  blood  circulating  in  these  vessels,  and  are 
very  efficacious.  At  other  times,  in  applying  them  to  these  parts, 
especially  after  having  practised  direct  depletion  of  the  uterine  vessels, 
we  succeed  in  diverting  the  current  of  blood  which  is  directed  too  in- 
tensely or  persistently  towards  the  uterus.  This  derivative  medication 
is  effected  still  more  efficaciously  in  certain  circumstances  vrhen 
applied  to  the  hypogastrium,  to  the  iliac  regions  or  to  the  loins.  In 
some  patients  this  application  acts  like  a  charm,  intense  pain  disap- 
pearing at  once.  In  these  cases  cupping  is  preferable  because  more 
powerful,  especially  in  cases  of  ovaritis  or  of  peritoneal  or  peri-uterine 
inflammation. 

But  of  all  the  modes  of  applying  leeches  the  one  I  practise  most 
frequently  and  successfully,  especially  in  cases  of  persistent  and  long- 
standing congestion,  chronic  metritis,  perimetritis,  ovaritis,  peri-uterine 
hsematocele  or  pelvic  inflammation,  is  that  of  applying  them  to  the 
cervix.  It  is  the  best  way  of  practising  local  depletion,  or  of  deter- 
mining a  derivation  by  means  of  the  uterus  and  the  community  of 
circulation  existing  between  this  organ,  the  Fallopian  tubes  and  the 
ovaries.  Whether  known  to  Zacutus  Lusitanus  and  Nigrisoli  of 
Perrara,  or  not,  the  application  of  leeches  to  the  cervix  in  our  days 
was  introduced  by  Guilbert^  and  adopted  by  Scanzoni  and  Aran. 
During  the  many  years  that  I  have  had  recourse  to  this  means  it  has 
invariably  produced  good  results.  Only  the  slight  difficulties  attending 
this  little  operation  and  the  necessity  of  watching  the  results  ought  to 
prevent  the  physician  from  delegating  it  to  others.  However,  with  a 
little  management  on  our  part,  this  mode  of  applying  leeches  is  not 
more  disagreeable  than  any  other.  The  patient  is  placed  on  the  edge 
of  the  bed  in  the  usual  position  for  examination  by  speculum,  the  legs 
close  together  and  flexed.  After  the  cervix  has  been  discovered  and 
embraced  by  a  long  cylindrical  speculum  and  the  mucus  carefully 
removed  we  put  seven  medium-sized  leeches  in  the  instrument  (a 
larger  number  would  not  have  room  for  sucking),  directing  them  to 
the  uterus,  where   they  are  kept  in   place  by  a  large  plug  of  cotton 

^  Considerations  pratiques  sur  certaines  affections  de  I'uterus.   Paris,  1826. 


METHODS    OF    TREATMENT    AND    MEDICATIONS  171 

wopl^  pushed  into  the  speculum  to  prevent  their  escape.  "When  that 
is  done  a  table  or  high  chair  may  be  brought  for  the  patient  to  rest 
her  feet  on,  whilst  she  is  entirely  covered  by  her  dress.  The  physi- 
cian, however,  must  carefully  hold  the  speculum  pressed  against  the 
cervix,  never  letting  it  go  for  one  moment^  so  as  to  prevent  any  of  the 
leeches  from  insinuating  themselves  between  this  instrument  and  the 
vagina,  and  sucking  the  latter  in  place  of  the  uterus,  or  escaping 
altogether,  as  I  have  often  seen  happen.  I  have  never  seen  pain  caused 
by  the  suction  except  when  the  cervix  has  been  ulcerated  or  the  os  so 
open  as  to  allow  the  entrance  of  the  leeches,  or  when  it  is  the  seat  of 
hypersesthesia  and  neuralgia,  which  not  only  prevent  the  extremity  of 
the  sound  from-  being  introduced,  but  will  not  even  permit  of  the 
uterus  being  touched  by  the  finger  (in  these  cases  the  pain  caused  by 
the  leeches  may  be  excruciating,  leading  to  hysteria  or  fainting).  This 
last  case  cannot  always  be  foreseen,  but  in  the  first  two  cases  it  is  easy 
to  prevent  pain  by  placing  a  little  cotton  wool  in  the  half-open  os,  and 
by  covering  the  ulcer  with  collodion. 

The  patient  does  not  usually  feel  the  leech-bites,  but  often  expe- 
riences a  peculiar  sensation  when  they  suck  with  most  activity,  or 
rather  at  the  moment  when,  under  the  influence  of  suction,  the  blood 
flows  towards  the  cervix  and  commences  to  flow.  It  is  a  sensation  of 
dragging,  of  traction,  which  appears  to  be  exercised  from  the  hypo- 
gastrium,  iliac  region  or  kidneys  towards  the  vagina ;  often  the 
starting-point  of  this  sensation  of  suction  is  in  the  diseased  organ,  the 
body  of  the  uterus  or  the  ovary,  and  specified  exactly  by  patients. 
About  twenty  minutes  afterwards,  and  most  frequently  after  the  patient 
has  felt  the  peculiar  sensation  to  which  I  have  just  referred,  the  blood 
is  seen  to  ooze  out  round  the  cotton  wool.  This  must  then  be 
removed  and  the  speculum  inclined  downwards,  so  as  to  allow  the  clots 
of  blood  to  escape ;  if  we  wait  a  quarter  of  an  hour  the  leeches  will 
follow.  We  must  count  them,  so  as  to  be  sure  that  none  have  re- 
mained behind ;  if  necessary  we  must  search  for  them  with  the  forceps 
at  the  bottom  of  the  speculum,  or  after  having  withdrawn  it  we  can 
discover  them  with  the  finger  in  some  corner  of  the  vagina  and  bring 
them  out.  The  whole  operation  does  not  last  more  than  half  an 
hour. 

If  the  leeches  have  taken  well  and  the  sanguineous  flow  be  sufficient 
we  shall  see  the  cervix,  which  was  swollen  and  dark  red  or  purple, 
become  pale  and  diminish  in  size ;  and  the  patient  often  at  once  expe- 
riences an  agreeable  sensation  of  depletion  ;  sometimes  she  says  that 
the  leeches  have  taken  away  her  malady. 

The  haemorrhage  generally  lasts  for  some  hours.  The  patient  must, 
therefore,  stay  in  bed  ;  if  the  haemorrhage  is  too  great,  a  plug  of  cotton 
wool  must  be  introduced  into  the  vagina,  which  will  moderate  it  by 
causing  coagulation,  and  the  patient  should  be  advised  to  lie  on  her 
back,  her  legs  together  and  flexed,  and  she  should  take  some  beef  tea 
to  keep  up  her  strength.  The  physician  ought  not  to  leave  her  without 
being  assured  that  the  blood  does  not  flow  too  abundantly.  If  the 
haemorrhage  is  excessive,  as  is  sometimes  the  case,   we  must  have 


172         TEEATMENT    OF    UTERINE    DISEASES    IN   GENERAL 

recourse  to  vaginal  injections  of  vinegar  and  cold  water,  and  not  leave 
the  patient  till  the  haemorrhage  is  stopped.  The  surest  way  of  doing 
so  is  to  introduce  the  speculum  again,  to  pour  a  little  water  into 
it  so  as  to  liquefy  the  blood,  to  remove  the  clots,  find  out  from  which 
point  the  hsemorrhage  comes,  to  introduce  a  tampon  saturated  with 
a  solution  of  perchloride  of  iron  (1  in  30),  and  then  plug.  If,  on 
the  contrary,  the  bleeding  is  insufficient,  leeches  must  be  applied 
again  the  same  evening  or  the  next  day,  so  as  to  obtain  the  requisite 
depletion. 

Scarification  of  the  cervix  may  also  be  employed.  Scanzoni^  and 
Mayer  have  had  scarificators  made  for  this  purpose.  The  ordinary 
scarificator  may  be  used,  or  a  lancet  may  be  employed  by  means  of 
Savage's  uterine  forceps.  The  scarifications  must  not  be  made  too 
deep  for  fear  of  wounding  vessels  of  considerable  size.  But,  as  a  rule, 
the  hsemorrhage  obtained  from  scarification  is  insufficient,  and  leeches 
have  always  seemed  to  me  preferable.  I  make  use  of  scarification 
when  it  is  necessary  to  deplete  a  large  cervix  before  cauterising  it. 
The  difficulty  of  obtaining  a  sufficient  depletion  by  scarification  of 
the  cervix  led  to  the  invention  of  a  cupping  glass  suitable  for  this 
organ,  which  induces  a  flow  of  blood  from  the  little  wounds  made  by 
the  scarificator.  Collin  invented  an  instrument  of  this  kind  which  he 
calls  a  uterine  leech,  and  Simpson  used  a  somewhat  similar  one. 

I  do  not  like  to  finish  the  history  of  bleeding  without  summing  up 
in  a  few  words  the  medications  which  it  reaUses  and  the  indications 
which  it  fulfils.  In  the  first  place  it  is  evident  that  recourse  ought 
not  to  be  had  to  bleeding  except  when  the  blood  plays  an  important 
part  in  the  existence  of  a  uterine  disease,  either  in  producing  fluxions 
by  the  impulse  given  to  it,  or  in  congesting  the  organ  by  the  dis- 
tension of  its  vessels,  or  lastly,  in  helping  to  keep  up  inflammation.  It  is 
therefore  evident  that  it  can  only  be  depletive,  derivative,  or  revulsive. 
With  reference  to  it,  therefore,  we  must  follow  the  rules  laid  down 
for  the  Methodic  treatment  of  fluxions,  and  for  the  use  of  depletion, 
derivation,  and  revulsion  in  general.  In  this  respect,  what  I  have  to 
say  with  regard  to  bleeding  will  be  applicable  to  other  evacuants,  to 
other  derivatives,  to  other  revulsives. 

We  cannot  do  better  than  take  the  treatise  of  Barthez  on  the 
methodic  treatment  of  fluxions2  for  a  guide  whenever  we  have  to  apply 
this  great  principle  of  general  therapeutics  to  any  special  case. 
Now,  fluxion  may  be  imminent,  or  recent,  or  fixed.  On  the  other 
hand,  the  inverse  movements  which  we  can  produce  on  the  blood, 
on  fluxion,  or  on  congestion,  by  means  of  bleeding,  evacuants, 
blisters,  attractives,  hydropathy,  &c.,  are  depletion,  which  consists  in 
directly  subtracting  from  too  full  an  organ,  derivation,  which  con- 
sists in  diverting  in  another  direction,  and  before  its  arrival,  the  fluid 
which  would  otherwise  have  been  carried  to  this  organ  where  it  would 

^  Lehrhuch  der  Krankheiten  der  weiblichen  sexual  Organen,  dritte  Auflage. 
Wien,  1863,  p.  38. 

■•^  Nouveaux  MUments  de  la  science  de  I'liomnie,  3*  edit.,  t.  ii,  p.  339.  Paris, 
1858. 


METHODS    OF  TREATMENT    AND    MEDICATIONS  173 

have  caused  congestion,  and  revulsion,  which  turns  aside  the  current  of 
this  fluid  in  order  to  direct  it  towards,  and  if  necessary  to  fix  it  in 
another  organ  more  or  less  distant,  the  organ  which  thus  becomes 
itself    the    seat    of  the  fluxion  relieving  the  other  which  has  kept 


Fig.  138. 


Pig.  139. 


Fig.  140. 


Fig.  138. — Mayer's  scarificator  for  the  cervix. 

Fig.  139. — Cupping-glass  witli  exhauster  for  the  cervix. 

Fig.  140. — Collin's  uterine  leech. 

up  the  disease  it  is  our  business  to  cure.  When  fluxion  is  imminent, 
revulsion  in  turning  the  course  to  quite  a  difl'erent  point  may  prevent 
its  fixing  itself  on  the  organ  which  we  wish  to  protect,  e.g.  bleeding 
from  the  arm,  emetics,  dry  cupping    of   the  breasts,    sinapisms    on 


174         TEEATMENT  OF   UTEEINE    DISEASES    IK    GENEEAL 

the  arms  in  the  case  of  imminent  uterine  fluxion,  whether  congestive 
or  hgemorrhagic.  When  fluxion  is  fixed  and  has  determined  recent 
congestion  of  the  organ,  the  current  of  blood  may  be  diverted  in 
another  direction  to  a  point  more  or  less  near  the  seat  of  congestion, 
e.  g.  by  leeching  or  cupping  the  vulva,  anus,  groins,  hypogastrium, 
loins,  in  case  of  recent  uterine  congestion  following  an  excess  of 
fluxion  with  insufficient  menstrual  haemorrhage.  When  fluxion  is 
fixed  and  of  long  standing,  and  cure  difficult  owing  to  habit  and  to 
the  loss  of  reaction  of  the  distended  vessels,  neither  revulsion  nor 
derivation  are  eff'ectual.  We  must  resort  to  evacuation  or  depletion 
in  order  to  diminish  the  excess  of  vascular  fulness,  e.  g.  by  leecliing 
the  cervix  in  congestion  and  chronic  metritis.  I  omit  details  given 
by  Bartliez,  and  will  also  avoid  going  into  them  myself  in  the  way 
of  applying  these  fundamental  principles  to  particular  cases.  But 
there  is  one  point  which  this  great  physician  seems  to  me  to  have 
neglected,  and  that  is  the  necessity  of  associating  revulsion  or  deri- 
vation with  depletion  in  cases  of  chronic  congestion,  and  associating 
them  in  an  inverse  order  from  that  which  we  adopt  when  using  them 
against  imminent  or  recent  fluxion.  In  short,  depletion  alone  will  not 
effect  a  cure ;  it  will  remove  the  excess  of  fulness,  but  not  the  habit 
of  fluxion.  The  bad  effect  is  only  destroyed  for  the  moment  and 
will  soon  be  reproduced,  for  the  cause  remains.  We  must  not  there- 
fore be  satisfied  with  having  emptied  the  excess  of  fulness  :  we 
have  not  destroyed  the  fluxion,  we  have  only  mobilised  it.  We 
must  quickly  take  advantage  of  this  circumstance  to  divert  it  by 
derivation,  directing  it  to  another  point  by  revulsion,  doing  it 
thoroughly  and  during  a  sufficient  length  of  time  for  the  uterus  to 
lose  the  habit  of  being  the  seat  of  attraction  to  this  fluxion. 

In  such  cases  we  must  almost  always  begin  by  leeching  the  cervix 
once  or  twice ;  but  after  the  fluxion  has  been  mobilised  by  this  deple- 
tion, and  if  necessary  by  another  as  a  derivative,  or  by  the  appKcation 
of  a  blister  to  the  neighbouring  parts,  we  must  take  advantage  of  this 
mobility  to  uproot  it,  and  by  revulsion  turn  it  aside  in  the  direction  of 
other  organs.  A  purgative  given  the  day  after  an  application  of 
leeches  fulfils  this  indication  perfectly  in  certain  cases,  and  some 
patients  from  this  moment  are  cured,  or  think  themselves  so ;  but  in 
most  cases  the  disease  is  of  too  long  standing  to  be  so  quickly  uprooted ; 
the  action  must  be  kept  up  by  cutaneous  and  intestinal  revulsions  of 
different  kinds,  especially  by  hydropathy,  the  best  of  all  revulsives, 
not  neglecting  tonics,  sedatives,  &c.,  nor  local  applications,  which  are 
generally  required  to  ensure  success. 

2.  Evacuants  or  purgatives. — Purgatives  are  used  with  a  twofold 
aim :  as  a  cure  for  constipation  or  as  a  revulsive.  It  is  absolutely 
essential  to  the  success  of  treatment  that  constipation  should  be  over- 
come. Neglect  in  this  matter  is  followed  by  increased  suffering,  dis- 
tension of  the  belly,  hypogastric  pain,  dull  aching  in  the  back  and  at 
the  anus,  swelling  of  the  epigastrium,  headaches,  &c.  Eegularity  of 
the  bowels  is  also  necessary  to  keep  up  the  appetite,  prevent  dys- 
pepsia and  increase  nutrition ;  in  fact,  it  is  one  of  the  most  important 


METHODS    OP    TREATMENT   AND    MEDICATIONS  175 

points  in  the  treatment  of  uterine  diseases.  It  is  best  to  begin  with 
simple  enemata,  cold  rather  than  warm ;  if  these  are  not  sufficient  medi- 
cinal enemata  should  be  tried,  laxative  rather  than  purgative,  a  decoc- 
tion of  lettuce  with  four  spoonfuls  of  olive  or  castor  oil  in  an  emulsion 
of  yolk  of  egg,  or  the  same  quantity  of  honey,  manna,  treacle,  or  gly- 
cerine, in  two  or  three  glasses  of  water,  with  occasionally  an  infusion 
of  half  an  ounce  of  senna  in  two  pints  of  water,  &c.  &c.;  if  necessary 
three  or  four  pints  should  be  prescribed,  the  patient  lying  on  her  back 
and  using  a  thick  and  very  long  gutta-percha  tube.  A  long  tube  is 
of  great  service  in  allowing  the  enema  to  penetrate  high  up  into  the 
intestine,  and  enabling  the  patient  to  retain  it  for  a  long  time.  Some- 
times the  uterus  or  a  peri-uterine  tumour  presses  on  the  rectum  and 
makes  it  as  difficult  for  the  enema  to  enter  as  for  the  faeces  to  be  ex- 
pelled. Enemata  ought  to  determine  a  real  evacuation  of  the  bowels. 
To  secure  this  the  long  gutta-percha  tube  ought  to  be  used,  and  the 
enema  should  be  laxative,  cold  or  tepid,  and  copious.  Attention  must 
also  be  paid  to  diet,  which  should  be  partly  composed  of  brown  bread, 
milk,  spinach,  prunes,  &c.,  and  if  necessary  mild  laxatives  must  be 
taken  in  addition,  such  as  whej',  vegetable  broth,  magnesia,  alone  or 
mixed  with  a  little  jalap  or  rhubarb,  castor  oil,  &c.  I  often  prescribe 
equal  parts  of  rhubarb  and  magnesia  (enough  to  cover  a  sixpenny- 
piece)  in  the  first  spoonful  of  soup,  or  a  teaspoonful  of  castor  oil  in  a 
cup  of  acorn  coffee. 

To  determine  revulsion  these  means  are  not  enough;  purgatives 
must  be  employed.  I  have  already  said  that  purgatives  are  generally 
indicated  after  leeching  the  cervix;  mild  laxatives,  frequently  repeated, 
are  the  best  resolvents  in  chronic  metritis  and  perimetritis.  Drastics 
ought  to  be  avoided;  scammony,  jalap,  aloes,  gamboge,  which  make 
up  the  pills  so  commonly  used  under  the  names  of  Anderson,  Morrison, 
Frank,  Bontius,  &c.,  have  the  disadvantage  of  congesting  the  lower 
part  of  the  intestine  and  the  uterine  system.  It  is  only  exceptionally 
and  in  very  small  doses  that  I  allow  their  use,  and  then  not  as  pur- 
gatives, but  to  prevent  constipation.  There  is  no  danger  in  occa- 
sionally giving  a  little  podophyllin  or  gr.  1^  of  aloes  with  gr.  f  of 
rhubarb,  so  long  as  their  use  does  not  become  habitual.  But  the  best 
purgatives  are  oils,  salts  or  tonics.  Of  oils,  half  an  ounce  of  castor 
oil,  alone  or  with  the  addition  of  one  drop  of  croton  oil,  is  quite 
sufficient,  especially  if  the  patient  has  taken  a  laxative  enema  the 
evening  before.  The  salines  most  generally  used  are  an  ounce  of 
Glauber's  or  Epsom  salts,  Seidlitz,  Hunyadi  Janos,  and  other  natural 
purgative  mineral  waters.  On  account  of  the  abundance  of  the  serous 
excretions  which  they  determine  they  cause  a  revulsion  very  favorable 
to  the  relief  of  the  uterine  system,  and  to  the  resolution  of  the  diseased 
organ ;  it  is  a  kind  of  white  bleeding.  If  castor  oil  is  counter-indicated 
by  the  coated  tongue,  and  saline  purgatives  by  atony  with  tendency  to 
irritation,  especially  if  there  is  a  bilious  condition  which  requires  pur- 
gation as  an  evacuant  as  well  as  a  revulsive,  rhubarb,  senna,  and  tonic 
purgatives  generally  may  be  resorted  to.  In  such  circumstajices  I  am 
accustomed  to  give : — Infusion  of  coffee,  one  ounce ;  senna  and  rhubarb. 


176  TREATMENT    OF    UTERINE    DISEASES    IN   GENERAL 

of  each  one  sixth  of  an  ounce ;  aniseed,  fifteen  grains  in  half  a  pint  of 
water,  adding  two  thirds  of  an  ounce  each  of  Epsom  salts  and  manna. 
In  obstinate  constipation,  kept  up  by  a  nervous  condition  (a  kind  of 
spasm  of  the  intestine),  and  in  the  case  of  patients  whose  stomachs 
cannot  tolerate  the  purgatives  just  referred  to,  belladonna  pills  are  very 
successful  (Sapon.  Med.,  5tj  Pulv.  Bellad.,  gr.  viii ;  Ext.  Bellad.,  gr. 
viii.  Misce;  divide  in  pil.  50.  Sig.  one  pill  every  night  at  bedtime). 
Sometimes  gr.  -^-ho  or  gr.  -^  of  strychnia  may  be  added,  or  pills  of 
sulphate  of  zinc.  Lastly,  on  rare  occasions  emetics  may  be  indicated, 
as  a  means  of  revulsion  in  fluxion  or  uterine  haemorrhage,  or  as  a  means 
of  perturbation.  In  this  case  we  may  have  recourse  to  antimony, 
in  the  dose  of  |-  to  1-|-  grains,  or  to  ipecac,  15  grains,  paying  atten- 
tion, of  course,  to  the  indications  and  counter-indications  to  the  use 
of  these  medicines. 

3.  Batks — Injections — Hydropathy — Mineral  Waters. — Under  this 
heading  I  include  the  use  of  water  in  every  form. 

A. — Hot  or  tepid  baths  are  usually  bad  in  the  treatment  of  chronic 
uterine  diseases.  They  must  not,  however,  be  absolutely  forbidden 
because  they  have  been  abused.  In  acute  inflammation  with  nervous 
erethism  of  the  uterus  or  neighbouring  organs  they  soothe  pain  and 
act  as  a  sedative  in  a  remarkable  way,  especially  if  used  long  enough 
at  a  time,  and  rendered  medicinal  with  bran,  starch,  hemlock,  poppy- 
heads,  belladonna,  &c. ;  they  should  be  taken  hot,  and  vaginal  irriga- 
tion should  be  made  the  whole  time.  They  act  as  sedative  fomenta- 
tions, and  in  certain  chronic  diseases,  such  as  cancer,  they  form  with 
emolhent  plasters  the  only  treatment  possible. 

General  tepid  baths,  whilst  soothing  in  acute  disease,  are  weaken- 
ing, therefore  they  cannot  be  continued  for  long.  Sitz-baths,  at  a 
temperature  beginning  at  80°  to  85°  Eahr.,  and  gradually  lowered 
every  day,  are  often  very  useful  taken  for  fifteen  or  twenty  minutes  at 
a  time.  Cold  baths  are  often  more  useful  than  hot.  I  do  not  mean 
baths  of  a  very  low  temperature;  but  in  the  majority  of  uterine 
diseases  it  is  well  to  take  baths  at  a  temperature  below  that  of  the 
body ;  the  bath  may  be  tepid  when  the  patient  enters  it  (if  a  reactive 
effect  is  not  required),  the  temperature  being  gradually  reduced  till  it 
is  cool  or  even  cold.  I  know  nervous  women  who  cannot  take  general 
baths  except  at  a  temperature  of  from  10°  to  15°  below  that  of  the 
body,  and  who  can  remain  for  half  an  hour  in  the  water.  I  speak 
especially  with  reference  to  sitz-baths;  if  hot  sitz-baths  are  open  to 
criticism,  it  is  not  the  same  with  reference  to  cold  ones,  which  ought 
almost  always  to  be  accompanied  by  vaginal  irrigations. 

B. — Injections  are  internal  local  baths.  Eew  medicinal  applications 
have  varied  as  much  as  these  in  composition,  form,  and  mode  of 
administration.  I  think  they  may  be  turned  to  good  account,  but 
on  condition  that  we  understand  the  effects  produced  better  than  has 
hitherto  been  done.  I  will  relate  my  experience  on  the  subject,  I 
distinguish  three  ways  of  applying  liquids  to  the  vaginal  cavity : 
injection,  lotion,  irrigation. 

a.  Injection  consists  in  the   introduction  of  a  liquid  intended  to 


METHODS    OF    TREATMENT   AND    MEDICATIONS 


177 


modify  the  vaginal  mucous  membrane  in  whole  or  in  part,  and  in  the 
prolonged  contact  (of  varying  duration)  of  this  liquid  with  the  parts 
on  which  it  is  to  act. 

When  the  physician  wishes  to  obtain  from  an  injection  all  that  he 
is  entitled  to  hope  from  it,  he  ought  to  make  it  himself.  An  ordinary 
syringe  of  medium  size  may  be  used  if  a  straight  uterine  tube  is  affixed 
to  it.  The  patient  should  be  on  her  back  in  the  position  described  for 
examination  by  speculum,  care  being  taken  that  the  pelvis  be  slightly 
raised.  Another  way  is  to  use  an  ordinary  syringe,  introducing  the 
tube  into  the  vagina  and  holding  it  pressed  against  the  vulva,  adding 
cotton  so  as  to  close  the  vaginal  orifice.  A  third  way  consists  in 
using  a  gutta-percha  syringe  without  a  tube,  the  same  size  as  the 
penis  or  larger ;  that  is  to  say,  exactly  filling  the  vaginal  orifice.  The 
extremity  should  be  rounded  and  pierced  with  holes ;  it  should  reach 
the  further  end  of  the  vagina,  but  in  proportion  as  the  piston  is  pushed 
to  expel  the  liquid,  the  syringe  ought  to  be  partially  withdrawn  to 
make  room  for  the  injection,  which  can  be  retained  in  the  vaginal 
cavity  as  long  as  desirable  by  simply  keeping  the  instrument  in  the 
entrance  of  the  vagina  so  as  to  close  it. 

h.  Lotion  is  really  washing  the  vaghial  mucous  membrane  by  the 
repeated  passing  of  a  liquid  over  the  whole  extent  of  it.  It  is  an 
excellent  way  of  cleansing  not  only  the  vaginal  walls  but  the  cervix. 
It  is  generally,  though  incorrectly,  called  injection.  Fortunately 
patients  can  generally  make  use  of  this  means  themselves.  Of  all  the 
instruments  for  this  purpose  the  one  I  prefer  is  the  liydroclyse,  because 


Fig.  141. 


Fig.  142. 

Fig.  141.— Ricord's  vaginal  injection  syringe. 

Fig.  142.— Hydroclyse  or  small  pump,  for  vagino-uterine  lotions. 

it  can  be  put  in  any  recipient,  can  be  used  for  almost  any  kind  of 
liquid,  and  its  mechanism  is  not  easily  put  out  of  order.  The  patient 
being  seated  on  a  bidet  in  which  is  the  liquid  for  the  lotion,  places  the 
hydroclyse  in  the  narrow  part  of  the  bidet,  and  slowly  introduces  the 
straight  tube^  well  oiled,  pushing  it  towards  the  back  to  the  further 
extremity  of  the  vagina ;  she  then  has  only  to  pump  for  a  few  minutes 

1  It  is  very  important  for  patients  to  use  straight  tubes  of  a  large  diameter, 
the  advantages  of  which  are  detailed  by  Delioux  de  Savignac  {Bulletin  tie 
ilUrapeutique,  t.  Ixxxv,  p.  159). 

12 


178 


TEEATMENT    OF   UTERINE    DISEASES    IN    GENEEAL 


to  secure  that  the  whole  of  the  liquid  shall  pass  over  the  vagina  several 
times.  Most  frequently  after  a  lotion  of  simple  water  or  soap  and 
water,  I  order  a  medicinal  one  for  ten  or  fifteen  minutes,  which  then 
acts  as  a  good  injection.  Lotions  are  indispensable  in  all  diseases 
causing  vaginal  secretions;  they  often  require  to  be  made  several 
times  a  day.  The  temperature  is  variable.  In  acute  inflammation  of 
the  uterus  or  vagina,  in  cancer,  and  in  certain  cases  of  hypersesthesia, 
the  lotion  ought  to  be  tepid.  In  chronic  inflammation,  in  leucorrhoea, 
engorgement,  hypertrophy,  deviation,  &c.,  it  ought  to  be  cold.  The 
nature  of  the  injection  also  varies ;  the  most  generally  useful  are  soap, 
carbolic  acid,  the  alkaline  carbonates,  vinegar,  alum,  tannin,  different 
preparations  of  iron,  especially  permanganate  of  iron,  aluminate  of 
iron,  perchloride  and  peroxychloride  of  iron,  &c.  In  using  lotions  the 
two  following  precepts  ought  to  be  attended  to  :  1.  Only  use  deter- 
gents, astringents,  cathartics ;  caustics  ought  only  to  be  employed  as 
injections  or  as  direct  applications.  2.  See  that  the  medicinal  lotion  is 
preceded  by  one  of  pure  water,  which  will  cleanse  the  mucous  surfaces 
of  the  secretions  which  cover  them. 

c.  Irrigation  is  nothing  more  than  a  prolonged  lotion.  It  is  an 
internal  bath  given  to  the  vagina,  the  cervix,  and  organs  contained  in 
the  pelvic  cavity.     Most  frequently  this  internal  bath  may  be  given 

simultaneously  with  a  sitz  or 
general  bath;  in  this  case  the 
vaginal  irrigator  may  be  used, 
but  the  hydroclyse  is  better. 

This  irrigation  may  be  pro- 
longed indefinitely,  but  ought 
not  to  last  less  than  from  a 
quarter  to  half  an  hour,  and  it 
ought  to  be  repeated  twice ;  but 
I  have  often  been  obliged  to 
continue  it  for  several  hours  and 
to  renew  it  after  a  short  interval, 
in  order  that  patients  may  derive 
the  full  benefit  from  a  means 
the  skilful  use  of  which  can 
produce  most  beneficial  results. 
Such  continuous  irrigation,  after 
cauterisation  or  any  other  trau- 
matic lesion,  is  an  excellent  way 
of  producing  a  sedative  efi'ect  on  the  uterus  and  uterine  system,  and 
of  preventing  a  fluxionary  movement. 

When  the  patient  is  confined  to  bed  the  double  vaginal  irrigator 
must  be  used.  This  ingenious  apparatus  allows  of  the  cervix  and 
vagina  being  kept  constantly  bathed  for  several  hours  by  a  liquid  at  a 
fixed  temperature,  without  the  bed  or  dress  of  the  patient  getting  wet. 
The  pipe  which  brings  the  liquid  terminates  in  a  tube  which  discharges 
it  near  the  cervix.  The  pipe  which  carries  the  liquid  away  takes  it  up 
near  the  vulval  orifice,  letting  it  simply  run  into  a  bucket  placed  near 


FiQ.  143. — Vaginal  irrisfator. 


METHODS    OF    TREATMENT    AND    MEDICATIONS 


179 


the  bed.  Both  tubes  open  into  the  vagina,  the  orifice  of  which  must 
be  perfectly  closed  or  the  apparatus  will  not  work.  In  Maissoneuve^s 
instrument  this  is  effected  by  the  swelling  of  an  air  pessary.  In  Aran's 
it  is  managed  simply  by  a  metaUic  plate  from  the  surface  of  which  a 
metallic  cone  arises  enclosing  the  two  tubes. 


Fig.  145 


Fig-  144. 


Fig.  146. 


Fig.  144. — Maisonneuve's  double  vaginal  irrigator. 
Fig.  145. — Vulvo-vaginal  extremity  of  Aran's  double  irrigator. 
Fig.  146. — Leroy's  double  canule  pessary  which  can  be  used  as  a  tube  for  the 
double  vaginal  inigator. 

c. — Kydropathy  is  one  of  the  most  powerful  means  in  the  treatment 
of  uterine  diseases.  It  comes  to  the  aid  of  so  many  medications, 
sedation,  tonification,  revulsion,  resolution,  without  enumerating 
others.  Unfortunately  it  is  often  used  blindly.  Hot  and  tepid  baths 
have  been  abused  as  well  as  bleeding,  rest,  &c.  Probably  it  will  be 
the  same  with  cold  water.  By  the  side  of  patients  who  have  been 
completely  cured,  are  there  not  others  who  have  been  victims  to 
hydropathy  which  has  been  made  fashionable  by  empirical  success  and 
recommended  too  indiscriminately  in  the  works  of  some  skilful  phy- 
sicians ?  If  we  would  enable  hydropathy  to  render  great  services  in 
the  treatment  of  uterine  diseases  (and  it  can  render  great  services),  we 
must  determine  the  nature  of  these  services,  at  the  same  time  pointing 
out  the  cases  in  which  it  may  be  injurious,  for  it  is  a  two-edged 
instrument. 

Cold  water  is  efficacious  in  uterine  diseases  as  in  all  chronic  dis- 
eases, even  in  inflammations,  but  under  certain  conditions :  for 
example,  if  acute  attacks  have  ceased;  if  the  hydropathy  be  employed 
according  to  the  strength  of  the  patient,  according  to  her  sensitive- 
ness, and  to  that  of  her  womb  ;  if  reaction  be  deteriikined  in  different 
ways  to  suit  different  patients,  by  walking  or  other  exercise,  moist  or 
dry  heat,  friction,   &c.,  according  to  general  strength  and  to   the 


180         TREATMENT    OF    UTERINE   DISEASES    IN    GENERAL 

special  susceptibility  of  diseased  organs,  for  sometimes  the  slightest 
exercise  is  followed  by  inflammatory  attacks. 

Physicians  who  are  at  the  head  of  hydropathic  establishments  must 
always  remember  that  cold  water,  like  any  other  medicine,  must  be 
variously  applied,  the  modes  of  reaction  modified,  and  the  whole 
system  of  treatment  suited  to  the  patient  and  to  the  disease.  The 
chief  aim  of  hydropathy  is  the  cooling  and  the  return  of  heat  to  the 
skin,  the  impression  made  on  the  organism  and  the  reaction  of  the 
latter,  concentration  and  expansion.  Cold  water  and  hot  air :  these 
are,  according  to  Tleury,^  the  bases  of  hydropathy.  These  alternations 
of  concentration  and  reaction  are  effected  by  means  of  cold  water,  i.e.  by 
an  agent  which  strengthens  the  economy  without  exciting  it,  and  which 
acts  on  the  organ  which  has  the  greatest  extent  of  surface,  i.e.  the 
skin,  at  the  same  time  that  it  stimulates  the  functional  vitality  and 
energy  of  all  the  viscera.  The  result  is,  that  a  frequently  repeated 
natural  revulsion  is  determined  on  the  largest  possible  surface  of  the 
body  J  and  that  it  has  a  resolvent  action  like  everything  which  stimu- 
lates nutrition,  repair  and  decomposition,  absorption  and  excretion. 
This  treatment  is  pre-eminently  tonic  for  the  diseased  organ  as  well  as 
for  the  whole  economy,  and  constitutes  a  medication  which  Aran  ^  has 
designated  by  the  original  expression  of  remontement  general.  Lastly, 
it  may  be  made  sedative  in  certain  cases,  by  prolonging  the  impres- 
sion of  cold  or  moderating  it  so  as  to  avoid  reaction.  Sometimes  one 
or  other  of  these  efl^ects  is  required  from  hydropathy,  sometimes  a 
combination  of  all.  Generally  it  is  employed  to  terminate  a  cure 
initiated  by  the  use  of  other  medicinal  agents  but  which  could  not  be 
effected  by  them  alone. 

There  are  cases  in  which  artificial  sweating  has  to  be  resorted  to, 
when  there  is  a  difficulty  of  reaction  in  a  patient,  or  when  a  powerful 
cutaneous  revulsion  is  necessary.  Artificial  sweating  may  be  deter- 
mined by  vapour  baths,  by  dry  heat,  or  by  wet  packs,  during  which 
the  patient  should  drink  an  infusion  of  lime-tree  flowers  with  a  few 
drops  of  acetate  of  ammonia,  and  when  sweating  begins  a  glass  of  cold 
water  every  quarter  of  an  hour.  This  sweating  may  either  precede  or 
follow  refrigeration.  This  means  has  the  drawback  of  weakening 
patients ;  but  it  is  very  powerful,  and  there  are  occasions  when  it  is 
most  beneficial.  The  sudden  impression  of  cold  may  be  produced  by 
friction  with  a  sponge  soaked  in  cold  water,  a  dripping  sheet,  wet 
compresses,  cold  enemata,  affusions,  immersion  in  a  bath,  in  a  river  or 
in  the  sea ;  by  sitz- baths  (which  may  be  of  running  water),  rain  baths, 
and  douches  of  all  kinds.  The  temperature  of  the  latter  ought  to  be 
from  45°  to  50°  Pahr. 

The  majority  of  these  means  can  be  employed  at  home  under  the 
direction  of  a  physician.  Great  attention,  however,  must  be  paid  in 
making  applications.  I  am  accustomed  to  begin  by  prescribing  dry 
frictions  :  these  frictions  should  be  made  morning  and  evening  with  a 

'  TraiUinatiqueetraisonned'hydrotlierapie.  Paris,  1'^  edit.,  1852  ;  2eedit., 
1857. 

2  Op.  cit.,  p.  261. 


METHODS    OP    TEBATMENT    AND    MEDICATIONS  181 

piece  of  flannel,  a  hair  glove,  or  better  still  a  brush  soaked  in  cam- 
phorated ammonia,  alcohol  or  tincture  of  bark.  After  a  while  this 
maj  be  changed  for  cold  sponging  or  the  dripping  sheet.  A  wet 
compress  may  be  used  also.  This  is  soaked  in  cold  water,  then 
wrung  out  and  wound  round  the  pelvis  with  dry  flannel  and  oil  silk 
over  it;  this  is  worn  for  eight  or  twelve  hours  without  being  changed. 
They  are  very  sedative,  but  should  only  be  used  in  summer.  Enemata 
of  cold  water  taken  at  bedtime  and  retained  all  night  are  also  very 
sedative  and  refreshing.  By-and-by  cold  sitz-baths  may  be  taken. 
They  are  either  merely  revulsive  or  they  become  sedative  according  to 
their  duration.  The  temperature  must  not  be  too  low,  especially  if 
they  are  of  running  water,  and  care  must  be  taken  to  elfect  a  good 
reaction. 

The  most  beneficial  applications,  however,  are  cold  affusions  and 
douches  ;  in  them  refrigeration  is  combined  with  titillation  or  more  or 
less  energetic  percussion  by  means  of  which  reaction  is  more  certainly 
produced.  The  douche  may  be  given  at  home  with  a  common  garden 
hose,  or  better  still  with  a  pump  having  an  air  reservoir  like  those  of 
Charriere  or  Mathieu,  in  which  the  force  of  projection  exercises  a 
more  efficient  percussion.  These  douches  ought  to  be  general;  seldom 
local,  on  the  sides,  loins  or  hypogastrium ;  never  on  the  cervix  nor  into 
the  vagina.  A  single  jet  may  be  used,  or  it  may  be  broken  by  a  rose. 
The  latter  is  preferable  as  a  rule.  Patients  ought  to  breathe  freely 
while  being  douched.  In  order  to  secure  this,  care  should  be  taken 
after  having  struck  the  feet  with  the  column  of  water,  to  make  it 
mount  upwards  by  the  legs,  pelvis  and  loins,  where  it  should  be  kept 
for  a  few  seconds,  then  to  diverge  obliquely  to  the  shoulders,  first  to  one 
side,  then  to  the  other,  without  striking  the  spine,  which  always 
causes  a  feeling  of  sufl^ocation.  The  patient  ought  to  move  and  rub 
herself  under  the  douche  in  order  to  facilitate  the  return  of  heat.  It 
is  enough  to  have  the  douche  once  a  day  on  rising,  or  during  the  day 
three  or  four  hours  after  a  meal.  It  ought  not  to  last  more  than  a 
minute  at  first;  but  may  by  degrees  be  prolonged  to  five  minutes.  In 
order  to  make  it  effective,  we  must  commence  by  determining  heat  to 
the  skin,  by  means  of  friction,  sweating,  or  best  of  all  by  walking  or 
other  exercise ;  this  is  what  is  called  action.  When  the  body  is  well 
warmed  the  patient  gets  her  douche.  Immediately  afterwards  she  is 
dried,  rubbed,  and  then  she  walks  again  till  she  perspires ;  this  is  what 
is  called  reaction. 

In  hydropathic  establishments  there  is  the  advantage  of  having 
very  strong  douches,  of  being  able  to  have  two  daily  and  to  multiply 
the  means  of  action  and  reaction ;  in  short,  of  employing  the  whole 
day  in  treatment  of  some  kind.  The  continued  regularity  of  the  treat- 
ment under  a  good  doctor  greatly  hastens  the  resolvent  effects  of 
hydropathy.  Hot  and  cold  douches  may  also  be  given  alternately, 
and  often  produce  great  effect.  In  many  establishments  treatment  is 
not  even  interrupted  at  the  monthly  periods,  but  it  is  more  prudent  to 
do  so  for  at  least  two  or  three  days,  and  especially  to  discontinue  cold 
sitz-baths.     Aran  mentions  a  case  in  which  serious  accidents  occurred 


182  TREATMENT    OF    UTERINE   DISEASES    IN    GENERAL 

because  this  precaution  was  not  taken.  Before  terminating^  let  me 
repeat  once  more  that  hydropathy  ought  never  to  be  employed  in 
cases  of  acute  disease,  nor  even  in  chronic  diseases  which  preserve  an 
acute  character,  nor  in  which  inflammatory  attacks  are  liable  to  occur; 
these  must  be  subdued  by  antiphlogistics,  blood-letting,  rest,  general 
baths,  purgatives,  &c.  In  short,  we  must  not  expect  the  impossible 
from  hydropathy,  but  it  can  do  much;  indeed,  without  it  I 
think  it  would  be  difficult  to  effect  a  cure  in  the  majority  of  uterine 
diseases. 

D.  Mineral  Waters  and  Medicinal  Baths — Mineral  waters  in  baths, 
irrigations,  douches,  as  well  as  artificial  mineral  or  medicinal  baths, 
produce  excellent  effects  if  applied  opportunely  and  according  to  the 
indication.  We  must  remember  that  mineral  waters  vary  greatly  in 
character ;  some  are  resolvent,  such  as  the  alkaline  waters  of  Yichy, 
Andabre,  Vals,  Boulou  j  others  are  revulsive  and  slightly  stimulating, 
e.g.  the  sulphur  waters  of  Luchon,  Saint  Sauveur,  Cauterets,  Vernet; 
others  tonic  and  more  or  less  stimulating,  e.g.  the  iron  waters  of 
Lamalou,  Sylvanes,  the  saline  waters  of  Balaruc,  sea-bathing,  the 
Bourbonne  waters,  &c.);  lastly,  some  are  sedative  (Bigorre,  Ussat, 
Neris,  &c.). 

We  must  remember  that  these  waters,  besides  possessing  the  pro- 
perties just  enumerated,  have  a  specificity  (if  I  may  use  the  expression) 
which  makes  them  valuable  in  diathetic  affections,  impoverishment  of 
blood,  dyspepsia,  and  all  the  general  conditions  on  which  uterine 
disease  is  often  dependent.  We  must  be  guided  by  these  two 
principles  in  choosing  a  watering  place  for  our  patients,  remem- 
bering that  mineral  waters  may  be  even  more  prejudicial  than 
hydropathy  if  employed  prematurely  before  acute  symptoms  are 
extinct. 

Sea-bathing  produces  very  different  effects  according  to  the  length 
of  the  bath,  the  climate  in  which  it  is  taken,  the  season  of  the  year, 
and  the  temperament  of  the  patient.  It  may  be  tonic  and  stimulating, 
or  it  may  exercise  a  very  energetic  resolvent  action  on  a  scrofulous  affec- 
tion, or  on  swellings  dependent  thereon.  An  intense  or  prolonged 
chill  is  to  be  avoided  in  women  exhausted  by  a  long  uterine  disease,  as 
well  as  in  persons  whose  power  of  reaction  is  weak ;  hence  the  inestim- 
able value  of  the  Mediterranean  for  delicate  and  enfeebled  constitutions. 
The  body  hardly  cools  in  the  water,  and  reaction  is  quick  on  coming 
out  of  the  sea  into  an  atmosphere  warmed  by  the  rays  of  a  burning 
sun.  The  burning  sand  is  also  of  great  value  in  bringing  back  heat 
to  the  extremities.  The  Atlantic  is  for  the  strong  who  can  support 
the  cold,  it  gives  them  renewed  strength ;  the  Mediterranean  is  for  the 
weak  and  chilly,  for  the  lymphatic,  for  those  who  have  neither  strength 
nor  heat  to  lose.^ 

The  waters  of  Balaruc,  Bourbonne,  and  other  saline  springs  possess 

the  same  qualities  j  they  are  purgative,  they  are  also  very  efficacious 

in  the  treatment  of  paralysis,  especially  of  essential  paralysis,  as  well  as 

of  nervous  hysterical  paralysis.     I  have  seen  a  case  of  paraplegia  of 

1  Uounc,  op.  cit.,  p.  317.     Paris,  1864. 


METHODS    or    TEEATMENT    AND    MEDICATIONS  183 

this  kind  in  a  young  lady,  which  had  lasted  for  two  years,  depriving 
the  legs,  bladder  and  rectum  of  all  power  of  contraction,  completely 
cured  by  the  Balaruc  waters.  As  a  rule,  however,  saline  waters  are 
too  exciting,  and  therefore  contra-indicated  in  the  treatment  of  uterine 
diseases. 

On  the  other  hand,  we  have  the  sedative  waters  of  Bigorre,  Assat 
and  Neris,  which  have  a  great  reputation,  and  to  which  some  physi- 
cians send  all  their  patients  indiscriminately.  They  are  absolutely 
inert  in  the  majority  of  uterine  diseases,  but  they  have  a  sedative 
effect  similar  to  that  produced  by  a  series  of  tepid  baths  of  ordinary 
water. 

The  alkaline  waters  of  Yichy,  Vals,  Boulou,  Andabre,  Plombieres, 
are  perhaps  those  which  produce  the  most  satisfactory  results.  They 
owe  their  success  to  the  influence  they  have  on  digestive  troubles  and 
to  the  resolvent  action  which  they  exercise  on  engorgements.  I  have 
had  some  remarkable  instances  of  success,  especially  in  associating 
them  with  hydropathy.  Villemin^  has  wisely  pointed  out  that  their 
use  is  absolutely  contra-indicated  where  inflammatory  symptoms 
exist. 

The  iron  waters  of  Lamalou,  Sylvanes,  Schwalbach,  Bussang,  Oreza, 
&c.,  are  often  of  great  service  also  in  curing  chloro-ansemia  and  dys- 
pepsia; they  enrich  the  blood  and  strengthen  the  constitution,  but 
sometimes  have  the  drawback  of  being  too  exciting.  The  consider- 
able amount  of  carbonic  acid  contained  in  the  Lamalou  waters  deter- 
mines a  temporary  hypereesthesia  of  the  skin,  which  is  afterwards 
followed  by  the  revulsive  effect  produced  by  the  absorption  of  carbonic 
acid,  i.  e.  a  marked  sedation  of  the  nervous  system. 

Lastly,  the  sulphur  waters  of  Luchon,  Saint  Sauveur,  Cauterets, 
and  especially  Vernet,  are  indicated  in  women  who  are  lymphatic,  scrofu- 
lous, leucorrhoeic  and  affected  by  catarrh  or  rheumatism.  In  addi- 
tion to  the  sedative  effects  of  some  springs  and  the  stimulating  effects 
of  the  great  majority,  they  have  a  revulsive  and  resolvent  action,  by 
which  remarkable  results  are  produced  in  a  great  number  of  patients, 
as  I  can  testify.  Yernet  is  especially  to  be  recommended  ;  it  is  habit- 
able all  the  year,  and  hydropathy  may  be  combined  with  the  use  of  the 
springs,  which  vary  greatly  in  temperature  and  composition. 

Medicinal  haths  are  often  useful  in  acute  uterine  diseases,  or  in  very 
painful  chronic  diseases,  such  as  cancer,  or  in  cases  of  great  debility 
associated  with  the  lymphatic  temperament.  They  are  generally  com- 
posed of  narcotic  or  sedative  plants — poppy-heads,  hemlock,  belladonna, 
henbane,  aconite;  or  of  emollient  substances — linseed,  bran,  glue, 
mallow ;  or  infusions  of  aromatic  plants  — lime-tree  flowers,  orange 
leaves,  thyme,  lavender,  rosemary,  sage. 

An  aromatic  bath  is  prepared  by  pouring  boiling  water  over  two 
handfuls  of  aromatic  herbs  and  covering  the  bath  witii  a  blanket,  the 
patient  waiting  till  the  temperature  is  sufficiently  low  to  allow  of  her 
taking  the  bath  comfortably.     When  aromatic  herbs  cannot  be  had 

^  De  I'emploi  des  eaux  de  Vichy  dans  les  affections  chroniques  de  I'uterus, 
pp.  126,  244.     Paris,  1857. 


184         TEEATMENT    OF    UTERINE    DISEASES    IN   GENERAL 

they  may  be  replaced  by  the  preparation  of  Pannes.  For  emollient 
baths_,  from  4  to  16  ozs.  of  glue  or  starch  is  dissolved  in  water,  or  a 
canvas  bag  containing  2  lbs.  of  bran  is  put  in  the  bath,  or  a  decoction 
of  mallow  or  linseed.  For  sedative  baths  a  decoction  made  from  1  oz. 
of  the  leaves  of  narcotic  plants  and  poppy-heads  mixed  together 
may  be  poured  into  the  bath.  For  a  sitz-bath  with  irrigation  one 
half  or  one  third  of  the  quantity  required  for  a  general  bath  is 
sufficient. 

Mineral  baths  may  be  prepared  in  many  ways.  I  think  the  simplest 
are  the  best : — 1  or  2  lbs.  of  common  kitchen  salt  for  saline  baths ; 
as  much  black  soap  or  from  7  to  10  oz.  of  carbonate  of  soda  for  alka- 
line baths;  from  3  to  4  oz.  of  sulphide  of  potassium,  previously  dis- 
solved in  water,  for  sulphur  baths.  As  for  chalybeate  baths,  I  think 
Lambossy's  recipe  is  the  best : — Take  five  or  six  quart  bottles  filled 
with  vinegar,  add  three  or  four  handfuls  of  iron  filings  to  each;  leave 
them  open  and  exposed  to  the  air ;  when  the  liquor  has  the  taste  of 
ink  it  is  ready  for  use.  One  bottle  is  enough  for  a  bath.  The  iron 
is  left  at  the  bottom  of  the  bottle,  which  can  be  refilled  with  vinegar. 
The  same  water  may  serve  for  several  baths  if  an  additional  half 
bottleful  is  used  each  time. 

4.  Resolvenfs,  including  all  the  agents  used  in  the  same  medica- 
tion, solvents,  alteratives,  and  special  stimulants,  such  as  electricity, 
are  often  indicated  after  antiphlogistics  and  bloodletting,  and  simulta- 
neously with  purgatives,  baths,  hydropathy  or  mineral  waters.  Dry 
rubbing  or  with  hartshorn,  alcohol,  bark  or  benzoin,  hydropathy  and 
purgatives,  are  all  powerful  resolvents  when  wisely  used,  but  not 
sufficient  of  themselves  to  dissipate  engorgement,  hypertrophy,  or  the 
remains  of  products  of  inflammation,  especially  when  these  morbid 
states  are  kept  up  by  the  existence  of  a  diathesis.  In  these  cases 
we  must  have  recourse  to  resolvents,  properly  so  called,  and  to  anti- 
diathetics. 

One  of  the  most  powerful  resolvents  that  can  be  used  on  account 
of  its  antiphlogistic  character  is  mercury  ;  it  diminishes  the  plasticity 
of  the  blood,  increases  the  absorbing  power  of  the  lymphatic  vessels 
and  stimulates  reabsorption.  I  generally  prescribe  it  on  the  abdomen 
and  groins.  I  add  to  the  uuguentum  hydrarg.  one  tenth  of  its  weight 
of  extract  of  belladonna,  an  excellent  sedative.  In  acute  disease  the 
application  is  repeated  every  six  hours,  placing  over  it  a  large,  hot 
and  very  moist  cataplasm.  Another  mode  of  application  is  to  spread 
a  thick  layer  of  this  ointment  on  a  piece  of  linen  large  enough  to 
cover  the  whole  abdomen,  and  leave  it  there  for  three  or  four  days,  taking 
care  to  cover  it  with  a  sheet  of  cotton  wool  and  oil  silk  which  keeps 
the  skin  moist  and  conduces  to  the  absorption  of  the  ointment  as  well 
as  to  the  subduing  of  the  inflammation ;  the  whole  should  be  kept  in 
place  by  a  bandage,  or,  better  still,  by  a  pair  of  knitted  swimming 
drawers. 

^.     Ung.  Hydrarg. 

Ung.  Simplic,  aa  5!  ; 

Tinct.  Opii,  IT^v  to  x  ; 

Ext.  Bellad.,  <rr.  i  to  gr.  f . 


METHODS    OF    TREATMENT   AND    MEDICATIONS  185 

When  the  use  of  mercurial  frictions  is  prolonged  care  must  be  taken 
to  prevent  salivation  by  occasionally  giving  a  glass  of  Seidlitz  or  Pullna 
water  and    telling  the  patient   to  be  particular  to    wash  the  mouth 


Fig.  147. — Instrument  for  injecting  ointment  into  the  rectum. 

frequently,  adding  a  little  carbolic  acid,  tincture  of  bark  or  guaiacum 
to  the  water.  She  should  also  use  a  solution  of  chlorate  of  potash  as 
a  gargle.  One  of  the  best  preparations  when  mercury  has  to  be  given 
internally  is  a  pill  containing  |  of  a  grain  each  of  calomel,  extract  of 
hemlock,  extract  of  dulcamara  and  white  soap;  one  to  four 
daily. 

In  diseases,  however,  which  have  become  chronic,  iodine  and  its 
compounds  are  more  frequently  useful.  Iodide  of  potassium  taken 
internally  has  a  very  powerful  resolvent  action.  It  is  well  to  begin 
with  1^  grains  daily,  which  may  be  gradually  increased  to  45  grains, 
and  then  diminished,  the  whole  treatment  lasting  for  about  three 
months.  Sometimes  it  is  better  to  give  this  medicine  as  an  enema : — 
Prom  3  to  30  grains  of  iodide  of  potassium  with  a  few  drops  of  lau- 
danum or  a  little  belladonna  or  chloral  in  from  1  to  3  ozs.  of  water. 
Simpson^  used  to  prefer  the  bromide  to  the  iodide  because  he  con- 
sidered it  a  sedative  and  tonic  as  well  as  a  resolvent.  The  sedative 
properties  of  this  salt  have  induced  all  practitioners  to  adopt  it.^  I 
do  not  sj)eak  of  the  other  preparations  of  iodine,  such  as  the  tincture, 
the  iodide  of  iron,  &c.,  which  '  are  less  frequently  used  in  these  cases, 
but  which  sometimes  render  great  service,  provided  they  are  not  contra- 
indicated  by  the  state  of  the  digestive  organs.  As  to  the  external  use 
of  this  drug,  I  sometimes  paint  different  parts  of  the  hypogastrium 
and  even  the  vagina  and  cervix  with  tincture  of  iodine,  which  acts  as 
a  revulsive  as  well  as  a  resolvent.  Sometimes  I  prescribe  frictions,  to 
be  made  in  the  evening,  with  an  ointment  composed  of 

^.     Ung.  Simp.,  3Ji  ; 

Plumb.  lodid.,  gr.  xlvj  ; 
Pot.  lodid.,  gr.  xxx, 

or  it  may  be  applied  in  the  same  way  as  the  mercurial  ointment. 

Preparations  of  gold  are  very  useful  when  mercury  and  iodine  are 
contra-indicated.  They  are  especially  useful  in  cases  of  scrofulous 
diathesis.  I  have  used  them  with  great  success  for  several  years ; 
under  their  influence  I  have  seen  three  ovarian  cysts  disappear,  and 
the  development  of  two  others  arrested.     Chloride  of  gold  and  sodium 

1  Clinical  Lectures  on  the  Diseases  of  Women.     London,  1872,  p.  385. 
-  Giibler,  De  la  puissance  sedative  clu  bromure  cle potassium,  dsLws  \e  Bulletin 
tjeneral  de  therapeutique,  t.  Ixvii,  pp.  5,  49.     Paris,  1861. 


186  TREATMENT    OE   UTEEINE    DISEASES  IN   GENEEAL 

is  given  by  rubbing  it  into  the  tongue,  beginning  with  gr.  ^,  and 
gradually  increasing  the  dose  by  an  additional  gr.  ^^  every  ten  days 
till  gr.  -jio  is  taken ;  or  it  may  be  given  in  solution  or  in  pills  from 
gr.  J-o  to  gr.  f  daily. 

I  have  also  found  arsenic  of  great  benefit  when  the  uterine  disease 
seemed  to  be  under  the  influence  of  a  herpetic  diathesis.  It  improves 
the  condition  of  the  blood  and  stimulates  nutrition.  I  generally  pre- 
scribe a  solution  of  gr.  f  of  arseniate  of  sodium  in  7  oz.  of  water,  a 
tablespoonful  twice  a  day.  The  dose  may  be  increased  by  adding  gr.  | 
every  week  till  44-  grains  are  taken  in  the  week. 

Alkaline  or  sulphur  waters,  tincture  of  colchicum^  and  Bonjean's 
dialysed  preparations  ought  not  to  be  neglected  in  cases  of  rheumatic 
or  gouty  tendency;  but  the  indication  for  the  two  latter  drugs  is  much 
less  frequent  than  for  the  others. 

Electricity  may  become  a  powerful  resolvent  by  the  special  excite- 
ment produced  in  the  uterine  tissue. 

I  must  also  mention  ergot  of  rye,  which  may  act,  though  in  an  in- 
direct way,  as  a  powerful  resolvent  on  this  organ.  It  causes  contrac- 
tions of  the  muscular  tissue  of  the  uterus.  Owing  to  its  special  action 
on  the  uterus,  as  well  as  to  its  haemostatic  properties,  it  not  only  arrests 
hsemorrhage,  but  it  determines  a  continuous  contraction  of  the  organ, 
which  is  transformed  into  an  expulsive  effort  when  a  polypus  or  other 
foreign  body  is  contained  in  it,  and  into  a  resolvent  action  when  this 
contraction  operates  on  the  organ  itself,  on  the  liquids  which  engorge 
itj  or  on  the  plastic  elements  interposed  in  its  tissue,  and  which 
increase  its  size  and  density.  Ergotine  may  be  used  or  ergot  of  rye 
in  powder  in  the  same  way  as  to  induce  delivery,  but  in  smaller  doses, 
3^  to  7  grs.  every  day. 

Lisfranc,  Nonat,  and  others  recomuuend  abstinence  or  the  gradual 
diminution  of  food  (the  Arabic  treatment),  as  stimulating  the  absorp- 
tion of  plastic  products  and  promoting  resolution.  Nothing  is  more 
logical,  and  I  admit  that  there  are  cases  where  this  treatment  should 
be  resorted  to.  But  these  cases  are  very  rare.  The  cura  /amis  requires 
very  great  prudence  on  the  part  of  the  physician  for  two  reasons  :  the 
first  is,  that  impoverishment  of  blood  and  debility  of  constitution 
generally  accompany  chronic  disease ;  the  second  is,  that  whilst  it  is 
true  that  the  resolution  of  chronic  phlegmasia  is  promoted  in  propor- 
tion as  the  patient  is  weakened,  we  are  also  assisting  the  diathesis  to 
profit  by  the  daily  increasing  debility  of  constitution  to  make  fresh 
inroads  on  the  organism. 

5.  To7iics  and  restoratives  are,  on  the  contrary,  absolutely  indicated 
in  the  majority  of  cases.  We  can  even  obtain  from  them  some  of  the 
beneficial  effects  of  the  cura  famis,  such  as  the  diminution  of  the  un- 
healthy stoutness  of  some  patients,  at  the  same  time  that  we  improve 
the  condition  of  the  blood  and  fibre,  the  tone  of  the  muscles,  the 
strength  and  resistance  of  all  the  organs.  A  generous  diet  is  the  best 
tonic;  abstinence  from  farinaceous  food  and  from  milk,  and  almost 
from  bread,  the  constant  use  of  roast  meat  with  green  vegetables  and 
fruit,  associated  with  vapour  baths,  frictions,  hydropathy,  exercise  and 


METHODS  OF  TREATMENT  AND  MEDICATIONS      187 

alteratives  will  strengthen  the  constitution  as  well  as  determine  the 
resolution  of  hypertrophy  or  tumours  formed  by  the  plastic  products 
of  chronic  phlegmasia.  In  order  to  derive  the  full  benefit  of  a 
generous  diet  we  must,  as  a  rule,  stimulate  digestion  and  also  give 
medicines  of  a  tonic  character  or  which  act  on  the  blood,  such  as  the 
chalybeates.  When  digestion  cannot  be  stimulated  by  a  change  to  the 
country  or  sea- side,  by  the  action  of  mineral  waters  and  hydropathy, 
we  must  have  recourse  to  anti-dyspeptic  medicines.  When  the  principal 
agent  of  digestion  is  wanting,  we  must  resort  to  pepsine,  alone  or 
associated  with  diastase,  lactate  of  soda  (3  grains  of  each),  morphia, 
strychnia  and  bismuth  taken  immediately  after  meals,  as  recommended 
by  Corvisart.^  When  the  secretion  of  the  gastric  juice  requires  to  be 
stimulated  we  should  give  a  bitter  or  aromatic  infusion,  a  little  ice  or 
alkalines  ten  minutes  before  meals,  as  advised  by  Blondlot,^  Corvisart,^ 
and  Longet.*  The  preparations  which  I  have  seen  most  successful  in 
this  case  are  the  following : — A  wineglassful  of  Yichy  water  (Source 
de  I'Hopital),  or  a  pinch  of  bicarbonate  of  soda  in  a  little  water,  a 
cupful  of  infusion  of  quassia,  alone  or  with  a  little  rhubarb,  or  a  tea- 
spoonful  of  absinth  liqueur ;  they  should  be  taken  ten  minutes  before 
meals,  and  be  varied  from  time  to  time.  At  other  times  I  give  one  or 
two  of  Gallard^s  pills^  during  meals.  When  there  is  nausea  with  ten- 
dency to  vomiting,  natural  or  artificial  effervescing  drinks  should  be 
taken  at  meal  times — seltzer  water  or  St.  Galmier,  Condillac,  Vergeze, 
or  Lamalou  water,  &c. ;  or  the  following  powder  may  be  prescribed  in 
a  little  orange-flower  water : — Calumba  root  and  calcium  carb.,  each 
gr.  3|^  with  belladonna,  gr.  -5%.  If  one  dose  is  insufficient  a  second 
and  a  third  may  be  taken  at  two  hours'*  interval.  If  the  tone  and  re- 
action of  the  stomach  are  defective,  an  infusion  of  bark  mixed  with 
wine  should  be  drunk  at  meals,  or  tar  water,  or  the  alkaline  chalybeate 
waters  of  Lamalou,  Boulou,  Yals,  A^ichy  (Celestin),  Andabre,  Bussaug, 
Orezza,  &c. ;  or  sometimes  even  cold  sulphur  waters,  or  artificial  pre- 
parations, simple  iron  water,  carbonate  of  iron,  or  the  peroxychloride 
of  iron.  When  there  is  habitual  diarrhoea,  Yichy  water  should  be 
taken  before  meals,  and  a  large  compress  of  flannel  and  oil  silk  should 
be  worn  over  the  abdomen,  or  the  abdomen  may  be  rubbed  with  croton 
oil.  Small  enemata,  with  a  few  drops  of  laudanum,  are  sometimes 
useful,  or  chalk  mixture,  bismuth,  &c.     Lastly,  morphia  in  solution 

'  Sur  la  dysjospsie  et  la  consomption  et  sur  I'ushge  de  la  pepsine.     Pans, 
1854.     See  also  O.  Eeveil,  Formulaire  raisonne  des  medicaments  nouveaux  et 
des  medications  nouvelles,  p.  92.     Paris,  1864. 
'  Traite  analytique  de  la  digestion.     Paris,  1843. 

3  De  la  secretion  du  sue  gastrique  sous  Vinfluence  directe  des  aliments, 
des  boissons  et  des  medicatnents.     Paris,  1857. 
■•  Traite  de  plujsiologie,  t.  i, -p.  184.     Pai-is,  1861. 
*  j^     Piperis, 

Pulv.  Myristic,  aa  gr.  xv  ; 
Pulv.  Cinnamon, 
Pulv.  Car^'ophylli,  aa  gr.  xxx  ; 
Assafoitid.,  gr.  Ix  ; 
Ext.  Tarax,  q.  s. 
Miscc,  divide  in  pil.  50,  silver.     Sig.  1  or  2  at  meal  times. 


188  TREATMENT    OF   UTERINE    DISEASES    IN    GENERAL 

(I  of  a  grain  in  30  minims  of  laurel  water),  or  laudanum,  or  tincture 
of  nux  vomica,  either  of  which  may  be  taken  in  doses  of  from 
1  to  6  drops,  may  be  of  great  use  in  calming  pain  or  exciting 
contractions  when  pain  or  inertia  of  the  stomach  are  the  causes 
of  dyspepsia. 

As  for  tonics  properly  so  called,  in  cases  of  chloro-anaemia  we  must 
have  recourse  to  one  of  the  numerous  preparations  of  iron.  One  of 
those  I  use  most  frequently  is  a  modification  of  Biaud^s  pills  made  by 
my  father:  R.  Mass.  Pil.  Blaud,  gr.  ijJ-;  Pulv.  Ehei,  gr.  |.  M. 
Pt.  pil.  1  to  4  before  each  meal.  This  preparation  of  iron  is  soluble, 
and  the  rhubarb  prevents  constipation.  I  often  add  valerian  to  the 
pills.  When  we  wish  to  associate  a  fattening  ingredient  with  the  iron, 
cod-liver  oil  mixed  with  syrup  of  iodide  of  iron  should  be  ordered. 

Lastly,  the  various  preparations  of  bark,  alone  or  mixed  with  milk, 
are  excellent  tonics  and  restoratives. 

6.  The  importance  of  sedatives  cannot  be  overrated  with  regard  to 
the  various  indications  which  they  fulfil  in  the  treatment  of  uterine 
diseases.  The  element  of  pain  is  the  one  we  have  most  frequently  to 
fight  against,  especially  when  localised  in  the  uterus  or  in  some  nerve. 
Local  or  general  hypersesthesia,  neuralgia  of  the  uterus  or  of  one  of 
the  sensitive  nerves,  e.g.  the  sciatic  nerves,  the  ilio-pubic,  an  inter- 
costal, or  a  branch  of  the  trifacial,  are  the  most  frequent  manifestations 
of  pain ;  they  indicate  tbe  use  of  ansesthetics  and  anodynes.  The 
preparations  of  opium  are  the  best  narcotics ;  they  may  be  associated 
with  belladonna  and  given  in  various  forms.  In  metritis  itself,  when 
an  element  of  excessive  pain  is  added  to  the  inflammation,  opium 
should  be  given  internally,  -f  of  a  grain  every  four  hours  or  every  hour 
if  necessary,  or  -jV  of  a  grain  of  hydrochlorate  of  morphia  every  six 
hours  till  the  pain  ceases.  Narcotics  may  be  also  administered  in  an 
enema  or  bath.  I  prefer  giving  15  or  30  drops  of  laudanum  by 
the  rectum  in  an  ounce  of  water  to  making  a  uterine  application ;  or 
the  groins  may  be  rubbed  with  laudanum,  or  a  suppository  of  opium 
and  belladonna  may  be  introduced  by  the  anus,  or,  better  still,  a 
sedative  pommade  may  be  injected  by  means  of  the  rectal  syringe  (fig. 
147,  p.  1S5).  Sitz-baths  are  often  of  great  use,  made  of  a  decoction  of 
60  grains  each  of  benbane  and  belladonna  leaves  to  10  quarts  of  water. 
Sometimes  a  cold  sitz-bath  with  irrigation  for  several  hours  is  sufficient 
to  cause  the  cessation  of  this  excessive  hypersesthesia,  especially  when 
brought  on  by  traumatism.  Yarious  sedatives  may  be  appKed  to  the 
cervix  itself,  belladonna,  laudanum,  &c.  As  to  the  application  of  cold, 
chloroform,  and  carbonic  acid,  it  is  better  to  apply  them  to  the  hypo- 
gastrium  than  to  the  cervix ;  the  first  is  followed  by  a  painful  reaction 
and  the  two  others  induce  congestion. 

Subcutaneous  injections  of  atropine,  or  hydrochlorate  of  morphia,  or 
even  of  chloroform,  succeed  wonderfully  in  neuralgia,^  and  I  always 
advise  their  use  if  anodyne  frictions  have  no  effect.  I  know  a  lady 
veho  has  given  herself  some  hundreds  in  the  iliac  and  crural  regions  to 

1  Des  injections  narcotiques  sous-cutanees  dans  le  traitevient  desnevralgies. 
Montpellier  medical,  t.  iii,  p.  289,  1859. 


METHODS  or  TREATMENT  AND  MEDICATIONS      189 

soothe  the  excruciating  pain  caused  by  compression  of  the  crural  nerve 
by  a  fibroma  of  the  broad  ligament.  They  can  be  made  in  the  hypo- 
gastrium^  in  the  sides,  thighs,  &c. ;  I  do  not  think  there  is  any  advan- 
tage in  making  them  into  the  uterus.  If  the  hquid  is  injected  into 
the  uterine  cavity,  how  can  the  dose  be  measured  ?  how  can  we  know 
that  a  single  drop  will  be  absorbed  ?  If  it  is  injected  into  the  tissue 
itself  the  puncture  causes  a  little  haemorrhage,  which  carries  away  a 
part  of  the  solution  with  the  blood.  I  confess  that  though  I 
have  been  in  the  habit  of  performing  this  little  operation,  I  have 
never  been  satisfied  with  the  way  in  which  it  was  done  nor  with  its 
results. 

The  other  element  depending  on  the  nervous  system  is  spasm  ;  it 
necessitates  the  administration  of  antispasmodics  under  all  forms. 
Sometimes  the  spasm  is  confined  specially  to  the  uterus  under  the 
form  of  cramp ;  sometimes  it  is  general,  and  may  even  give  rise  to 
hysterical  attacks.  Laudanum  given  in  an  enema  is  often  sufficient  to 
alleviate  these  colics.  Cold  water  in  many  circumstances  acts  as  an 
antispasmodic.  Infusions  of  lime  tree  flowers,  orange  leaves,  balm,  &c. 
are  also  useful ;  but  when  there  is  constriction  of  the  throat,  nausea, 
convulsive  or  tetanic  movements,  angesthesia,  &c.,  we  must  employ 
stronger  remedies.  Inhalations  of  ether  or  chloroform  often  succeed ; 
or  these  medicines  may  be  administered  by  the  mouth  in  the  form  of 
capsules;  when  these  remedies  are  not  sufficient,  ammonia,  camphor, 
galbanum,  ambergris,  valerian,  musk,  or  castoreum  may  be  tried. 
Ambergris  and  musk  are  so  costly  that  I  generally  use  valerian  and 
castoreum  associated  with  laudanum  and  sulphuric  ether;  I  mix  these 
four  substances  in  equal  parts,  and  prescribe  15  to  30  drops  in  half  a 
tumbler  of  water  with  a  spoonful  of  orange  flower  water,  to  be  taken 
in  spoonfuls  every  five  minutes.  These  antispasmodic  drops  generally/ 
give  immediate  relief,  and  it  is  a  convenient  preparation  for  patients  to/ 
have  beside  them.  When,  however,  the  symptoms  assume  a  still  more} 
serious  aspect,  assafoetida  should  be  given  in  pills  or  in  an  enema' 
(assafoetida  gr.  Ix,  tr.  opii  min.  xv,  mixed  with  the  yolk  of  an  ^^^  in! 
3  oz.  of  water),  and  sinapisms  applied  to  the  extremities,  the  pul- 
monary, epigastric,  and  cardiac  regions.  The  use  of  electricity  under 
the  form  of  the  continued  current  may  also  render  great  service  in  the 
treatment  of  uterine  pain  and  spasm. 

7.  Epispastics  and  exulories  may  be  employed,  especially  in  the 
treatment  of  chronic  diseases.  They  act  as  derivatives  rather  than  as 
revulsives,  for  example  in  mucous  discharges;  and  sometimes  as 
resolvents,  for  example  in  the  treatment  of  engorgements  and  chronic 
peri- uterine  phlegmasia.  Exutories  may  be  used  in  cases  of  diathesis, 
but  I  confess  I  dislike  this  mode  of  treatment,  especially  for  young 
women,  and  prefer  revulsion  towards  the  skin  by  means  of  hydropathy, 
not  only  because  it  is  less  repugnant,  but  because  it  is  much  more 
natural,  being  exercised  on  a  large  surface,  and  consequently  more 
efficient  and  energetic  than  the  best  exutories.  I  reserve  them  for 
serious  cases,  where  complications  such  as  phthisis  prevent  the  use  of 
hydropathy. 


190         TREATMENT    OF    UTERINE    DISEASES    IN    GENERAL 

Epispastics  properly  so  called  (blisters)  have  a  double  action,  being 
derivative  as  well  as  resolvent  when  applied  near  the  seat  of  evil.  In 
cases  of  chronic  metritis,  peri-uterine  inflammation,  ovaritis,  engorge- 
ment, hypertrophy,  they  should  be  applied  to  the  loins  and  even  to 
the  sacral  region,  to  the  abdomen,  hypogastrium,  or  one  or  other  of 
the  iliac  regions ;  they  ought  to  be  proportioned  to  the  extent  and 
duration  of  the  inflammation.  For  an  extensive  but  recent  inflam- 
mation, pelvic  peritonitis  for  example,  a  large  bhster  is  apphed, 
covering  the  greater  part  of  the  abdomen  or  one  of  the  iliac  regions  ; 
it  should  be  left  for  about  twenty-four  hours  till  the  blister  is  well 
formed.  It  is  then  gently  punctured  with  a  needle  to  allow  the  escape 
of  the  serous  fluid,  care  being  taken  not  to  remove  the  skin;  it  is  then 
covered  with  cotton  wool  which  is  kept  in  place  by  a  tight  bandage  to 
prevent  friction.  For  a  long  standing  but  circumscribed  inflamma- 
tion or  for  an  engorgement  or  hypertrophy  it  is  better  to  apply  a 
number  of  small  blisters  (the  size  of  a  crown  piece)  successively ;  the 
first  in  the  centre,  the  others  round  about  it. 

Blisters  may  also  be  applied  to  the  cervix.  I  have  seen  them  cure 
obstinate  leucorrhcea.  They  are  also  useful  in  cases  of  perimetritis, 
and  in  all  those  cases  where  it  is  desirable  to  relieve  the  uterus  by 
means  of  a  serous  discharge,  or  to  produce  a  rapid  and  temporary 
vicarious  action.  These  applications  are  made  as  follows :  after 
removing  all  mucus  from  the  uterus,  a  blister  rather  smaller  than  the 
cervix  is  applied  to  it,  and  kept  in  place  by  pledgets  of  cotton  wool ; 
after  inserting  a  number  of  small  ones  a  large  one  ought  to  be  intro- 
duced. These  precautions  are  absolutely  necessary  to  prevent  the 
blister  from  touching  the  vagina  which  would  cause  intense  pain. 
After  remaining  for  a  few  hours  or  a  day  it  should  be  withdrawn, 
when  a  very  abundant  serous  secretion  takes  place  which  generally 
lasts  for  a  few  days.  It  is  useless  to  apply  any  dressing,  but  emollient 
irrigations  should  be  made  morning  and  evening. 

2.  Local  means 

Local  or  topical  means  are  of  three  kinds  :  mechanical  appliances, 
medicated  applications  and  surgical  operations. 

1.  The  mechanical  means  applied  externally  are  :  various  kinds  of 
abdominal  belts  and  perineal  pads.  The  former  act  on  the  abdominal 
viscera,  the  latter  on  the  uterus.  We  must  distinguish  between  two 
kinds  of  belts  :  abdominal  belts,  the  object  of  which  is  simply  to 
support  or  compress  methodically;  and  hypogastric  belts,  which  only 
act  on  the  viscera  in  the  way  of  supporting  them  so  as  to  protect  the 
uterus  indirectly. 

Abdominal  belts  may  act  either  on  the  whole  of  the  abdominal  walls 
or  on  its  lower  part.  The  object  of  the  former  is  to  compress  the 
abdomen  methodically  when  too  much  distended  by  adipose  tissue, 
when  the  size  of  the  belly  becomes  troublesome,  or  when  tlie  parietes 
(enfeebled  by  distension  caused  by  previous  pregnancies  or  ascites)  are 
relaxed,  hanging  down  over  the  pubis,  and  requiring  to  be  supported 
in  order  not  to  hinder  exercise  and  cause  fatigue.     This  methodic 


METHODS    OF    TREATMENT    AND    MEDICATIONS  191 

compression  may  be  exercised  with  advantage  on  distension  produced 
by  ovarian  cysts  during  their  development,  after  evacuation  of  the 
fluid  by  puncture,  or  even  after  the  removal  of  the  cyst.  I  have  seen 
such  striking  examples  of  the  efficiency  of  abdominal  belts,  that  I 


\ 

\  i  / 

Fig.  148. —  Bourjeai^rd's  abdominal  Fig.  149. — Courty's  belt  for  methodic 

belt  or  suj)port.  compression. 

cannot  but  recommend  their  use.  The  introduction  of  india  rubber 
into  the  materials  used  for  this  compression  allows  of  a  great  degree 
of  precision  being  attained  in  the  application  of  these  belts,  and  at  the 
same  time  renders  them  impermeable,  which  makes  them  of  great  ser- 
vice when  it  is  desirable  to  maintain  a  moist  heat  round  the  pelvis. 
In  this  respect  I  cannot  too  highly  recommend  Bourjeaurd's  elastic 
belts}  The  difficulty  of  exercising  a  sustained  and  regular  compres- 
sion when  the  abdomen  presents  inequalities  or  contains  an  irregular 
tumour,  or  during  the  evacuation  by  paracentesis  of  the  fluid  of  an 
ovarian  cyst  or  of  ascites,  led  me  long  ago  to  invent  a  hell  exercising 
metJwdic  compression.  It  is  simply  composed  of  a  dozen  little  straps 
of  girth  webbing  alternating  with  a  dozen  little  buckles,  both  being 
fastened  to  a  single  piece  of  strong  ticking  which  forms  the  lumbo- 
sacral part  of  the  belt.  In  buckling  the  straps  alternately  right  and 
left,  beginning  either  from  above  or  below  and  increasing  the  con- 
striction proportionally,  the  whole  of  the  antero- lateral  abdominal 
parietes  are  compressed  in  the  most  regular  manner.  In  paracentesis 
this  belt  obviates  the  necessity  of  having  assistants. 

Hypogastric  belts,  as  their  i^me  indicates,  concentrate  their  action 
on  the  hypogastrium.  Their  essential  part  consists  of  a  strong  pad, 
very  thick,  sometimes  elastic,  but  more  frequently  not,  hard,  resistant, 
stuff'ed  with  horsehair,  lined  with  strong  chamois  leather  on  the  hypo- 
gastric side,  and  supported  by  a  broad  metallic  plate  outside.  These 
are  not  intended  to  compress  the  uterus  in  any  way,  still  less  to  render 
it  fixed,  but  only  to  raise  and  support  the  abdominal  viscera,  in 
order  to  prevent  them  from  weighing  painfully  on  the  diseased  womb. 
These  belts  ought  to  have  the  opposite  effect  from  the  corset.  The 
corset  pushes  all  downwards ;  hypogastric  belts  ought  to  raise  all  up- 

'  Gazelle  des  hopitaux,  24  Janvier,  1857. 


192 


TEEATMENT    OF    UTERINE    DISEASES    IN    GENERAL 


wards;  hence  the  uterus  is  protected.  The  principal  part  of  the 
apparatus  therefore  is  an  elastic  pad,  or  a  plate  supporting  a  strong 
pad  of  horsehair,  to  which  a  key  has  been  adapted  which  allows  of 
variation  in  the  slope.  As  for  the  way  in  which  the  pad  is  maintained 
in  place,  sometimes  a  broad  band  is  used,  like  the  soft  belt  for  sup- 
porting the  hypogastrium  in  pregnancy ;  or  a  stronger  band,  like 
that  used  in  the  bandage  for  hernia  (E-aynal^s  system).    Sometimes 


Fig.  150. — Bour-  Fig.  151. — Hypogastric  belt  with 
jeaurd's  hypo-  springs  and  articulations,  and  pad 
gastric  belt.  with  key. 


Fig.  152.  — Bour- 
jeanrd's  belt  for 
anal  or  nterine 
prolapsus,  with 
peiinaeal  pad. 


elastic  springs  are  used,  having  their  point  d'appui  behind  on  the 
sacrum,  which  by  means  of  double  articulation  allow  movements  in  all 
directions  without  displacing  the  pad  (Charriere's  and  Mathieu's  belts 
are  like  these).  Whichever  belt  is  applied,  the  band  or  springs  ought 
always  to  pass  under  the  crest  of  the  ilium.  In  cases  where  median 
compression  would  be  painful  for  bladder  or  uterus,  it  is  replaced  by 
bilateral  compression,  exercised  by  means  of  two  pads  on  the  right  and 
left  of  the  Unea  alba,  leaving  a  little  space  between  them. 

The  perineal  pad  acts  on  the  uterus,  but  it  acts  externally,  not  in- 
ternally like  pessaries,  and  in  that  respect  is  often  superior  to  them 
because  better  borne.  It  is  indicated  in  cases  of  prolapsus,  and  even 
in  cases  of  hypertrophic  elongation  of  the  cervix.  It  consists  of  a  large 
pad  of  hair,  india-rubber,  gatta  percha,  or  even  wood,  pressed  against 
the  perinseum  by  means  of  straps  fastened  to  a  good  belt.  Sometimes 
the  pressure  that  is  necessarily  exercised  causes  a  dragging  on  the 
thighs,  which  would  let  the  belt  slip  if  ^ot  kept  in  place  by  shoulder- 
braces  like  Demarquay's.^ 

It  has  been  proposed  to  introduce  mechanical  supports  into  the 
rectum,  with  the  view  of  removing  uterine  retroversion  by  distending 
the  rectum  with  one  of  Gariel's  pessaries.^  It  is  introduced  into  the 
intestine  in  a  flaccid  state,  and  then  distended  with  air  by  means  of  a 
syringe,  or  pledgets  of  lint  may  be  introduced  of  a  gradually  increased 
size.^  Every  one,  however,  must  foresee  that  these  means  must  be  very 

'  Gazette  des  Mpitaux,  1860. 

^  Favi'ot,  Revue  medico -cliirurgicale,  novembre,  1851. 

^  Huguier,  De  VHysUrometrie,  p.  3B8.     Paris,  18fi5. 


METHODS    OF    TREATMENT    AND   MEDICATIONS 


193 


troublesome,  causing  a  constant  desire  to  go  to  stool,  irritating  the 
intestine,  and  tending  to  produce  tenesmus. 


Fig.  153. — Velpeaii's  pessary,  having  the  form  of  the  vagina. 


Fig.  154. —  Sponge  filling  the  vagina 
and  serving  as  pessary. 


Fig.  155. — Gariel's  globe  air  pessary 
filling  the  vagina. 


2.  Internal  mechanical  supports  are  known  as  Vaginal  pessaries ; 
they  are  very  numerous,  but  in  this  case  we  may  say,  as  in  that  of  every 
other  therapeutical  problem  which  is  apparently  distinguished  by  the 
variety  of  ways  in  which  it  can  be  solved,  that  this  seeming  wealth 
only  conceals  real  poverty.  They  may  be  distinguished  according  to 
the  parts  which  they  support  and  those  which  they  take  for  their  point 
d'appui.  Some  support  the  uterus  by  filhng  the  vagina  and  taking 
its  shape,  like  Eecamier's  emollient  or  aromatic  bags,  or  the  pessaries 
of  Velpeau  or  Cloquet ;  others  distend  the  vagina  in  every  direction 
like  the  globe  pessaries  (of  wood,  ivory,  or  metal),  or  fine  sponge  (fig. 
154),  which  is  the  simplest  of  all  pessaries,  in  spite  of  the  drawbacks 
pointed  out  by  Lisfranc,  or  like  Gariel's  air  pessary  (fig.  155),  which 
is  very  easily  introduced  when  empty  (fig.  156)  and  which  can  be 
afterwards  inflated  (fig.  157). 

Others,  in  place  of  taking  the  shape  of  the  vagina  or  distending  it 
in  every  direction,  only  distend  it  in  one  zone,  exercising  excentric 
pressure  on  its  walls  in  a  circular  manner,  the  edge  of  the  inferior  strait 

13 


194  TEEATMENT   OF    UTEEINE    DISEASES  IN   GENEEAL 

serving  as  a  point  d'appui,  which  allows  the  uterus  to  rest  on  this 
artificial  floor  (Figs.  158,  159,  160).  They  are  supported  by  the  bones 
of  the  pelvis.    These  ring  pessaries  are  either  made  of  hard  substances. 


Fig.  156. — Gariel's  globe  pes- 
sary empty. 


Fig.  157. — Gariel's  globe  pessary  distended 
with  air. 


such  as  wood,  metal,  or  vulcanite,  or  of  India  rubber  distended  by  air 
(Pigs.  162,  163, 164).     They  are  generally  perforated  in  the  centre  to 


Fig.  160. 


Fig.  161. 


Fig.  158.  Fig.  159. 

Fig.  158. — Circular  ring  pessary. 
Fig.  159. — Elliptical  ring  pessary. 
Fig.  160. — Pessary  in  form  of  figure  of  8. 

Fig.  161. — Funnel-shaped  pessary,  hollowed  out   in   front  and   applied  in  cases 
of  retroversion. 

allow  the  uterine  secretions  to  escape.  These  pessaries  have  been  used 
not  only  for  prolapsus  but  also  for  deviations,  especially  retroversion 
or  retroflexion,  by  making  their  two  opposite  segments  very  unequal, 
for  example,  the  posterior  very  large  and  the  anterior  very  small 
(Figs.  161  to  16-1).  The  greatest  improvement  that  has  been  made  is 
their  reduction  to  a  simple  ring,  which  is  very  light,  and  distends  the 


METHODS    OF    TREATMENT   AND    MEDICATIONS  195 

upper  part  of  the  vagina,  being  kept  in  position  by  its  own  flatness. 


Fig.  162.— India- 
rubber  ring  pes- 
sary inflated. 


Fig.  163. — India-rubber  ring 
and  air  pessary  intended  for 
cases  of  retroversion. 


Fig.  164. — Air  pessary 
excavated  in  front. 


Tliese  modifications  have  originated  the  pessaries  which  go  by  the 
names  of  Meigs,  Dumontpallier,  and  Gairal  de  Carignan.^ 


Fig.  165.  Fig.  167. 

Fig.  165. — Meigs's  watcb-spring  ring  pessaiy  covered  with  gutta  percha,  it  has 
recently  been  imitated  by  Dumontpallier. 

Fig.  166. — Gairal's  ring  pessaiy,  differing  from  Fig.  165  in  the  ring  being  flat 
instead  of  round,  which  prevents  its  slipping  after  being  placed  in  the 
upper  part  of  the  vagina  which  it  is  intended  to  distend. 

Fig.  167.— Method  of  introducing  the  pessary  into  the  upper  part  of  the  vagina. 

Other  pessaries  distend  the  vagina  in  a  straight  line,  or  in  an  axis 
the  extremities  of  which  seem  to  be  the  two  ends  of  a  lever  supported 

'  All  these  pessaries  are  considered  useful  in  anteversion  (preventing  the 
cervix  from  inclining  towards  tlie  posterior  wall  of  the  vagina)  and  in  retro- 
version (preventing  the  fundus  from  falling  backwards).  But  it  is  sometimes 
necessary  to  place  the  posterior  side  in  front,  which  proves  that  they  act  less  in 
redressing  the  uterus  than  in  supporting  it. 


]96 


TREATMENT    OF    UTERINE    DISEASES    IN    GENERAL 


simply  by  the  pressure  which  the  stretched  vaginal  walls  exercise  on 
them.  Sometimes  they  distend  the  upper  part  of  the  vagina  across,  or 
from  one  side  to  the  other,  before  or  behind  the  uterus.  The  most 
primitive  of  these  instruments  is  the  simple  spring  to  which  Kilian 


Fig.  168, — Zwanck's  Hysterophore.     1,  when  being  introduced ;  2,  kept  open 

in  the  vagina. 

has  given  the  pompous  name  of  elytromochlion  (vaginal  lever) ;  others 
consist  of  two  wings,  which  are  closed  whilst  the  instrument  is  being  intro- 


Fm.  169.- 


-Schilling's  hystero- 
phore. 


Fi&.  170. — Zwanck's  hysterophore 
modified  by  Savage. 


duced  and  opened  when  it  is  in  place.  They  are  kept  in  position  by  a 
screw  fitted  into  one  of  the  stems  (as  in  Zwanck's  hysterophore);  or  by 
a  simple  hook  at  the  end  of  one  of  the  stems  into  which  the  end  of  the 
other  fits  (as  in  Weiss^s  hysterophore) ;  or  by  a  vice  common  to  the 
two  stems,  regulating  the  degree  of  divergence  (Schilling's) ;  or  by  an 
elastic  ring  (Eulenburg's) ;  or  better  still  by  an  india-rubber  tube 
split  at  the  top,  which  is  attached  to  both  wings,  keeping  the  stems 
closed  in  the  vagina  (Savage's),  which  is  the  simplest  and  therefore 
the  best  (Figs.  168  to  171).     Sometimes  they  distend  the  vagina  from 


METHODS  OF  TREATMENT  AND  MEDICATIONS 


197 


before  backwards  as  well  as  support  the  uterus.  Such  are  the  excavated 
pessary  for  retroversion,  the  battledore  pessary  of  Hervez/  the  trian- 
gular one  of  Simpson  and  Priestley,  which  rests  on  the  vagina  on  one 


Fig  171. — Zwanck's  hysterophore  modified  by  Eulenburg  :  1,  shut ;  2,  open. 

side  and  on  the  perineum  on  the  other.     Such,  too,  are  Hodge's  lever 
pessary  and  Graily-Hewitt's  cradle,  which  rest  on  the  posterior  cul- 


FiG.  172. — Hervez'  battledore       Fig.  173. — Simpson's  and  Priestley's 
pessary.  triangular  pessary. 

de-sac  on  the  one  side  and  on  the  anterior  wall  of  the  vagina  on  the 
other. 

I  have  modified  the  latter  pessaries,  adapting  them  to  the  cure  of 


Fig.   174. — Hodge's  horse- 
shoe pessary,  silver  gilt. 


Fig.  175. — Hodge's  lever  pessary  of 
silver,  gutta  percha  or  tin.  The 
same  in  aluminium  (Sims). 


retroflexions  by  hollowing  out  the  posterior  part  of  the  ring  so  as  to 
push  back  the  cervix  instead  of  passing  behind  it  and  pushing  back  the 

'  De  quelques  deplacements  de  la  matrice  et  des  pessaires  les  plus  conven- 
ables  pour  y  remedier,  Memoires  de  VAcademie  de  medecine,  t.  ii,  p.  319. 
Paris,  1833. 


198 


TREATMENT   OF    UTERINE    DISEASES    IN    GENERAL 


vagina.  It  is  a  good  plan  to  try  them  first  in  each  patient,  choosing 
them  of  the  size  and  shape  best  suited  to  each,  and  on  the  first  appli- 
cation to  use  rings  of  tin  or  lead,  which  take  any  form  given  to  them. 


Fig.  176. — Hodge's  pessary  in  position      Fig  177. — Hodge's  pessary  modified 
for  retroflexion.  by  Conrty,  so  as  better  to  maintain 

the  reduction  of  tlie  retroflexion. 

Afterwards  they  should  be  made  on  this  model  in  aluminum,  a  light 
and  unalterable  metal,  which  is  so  well  tolerated  by  patients  that  it 


Fig.  178.— Graily-Hewitt's 
cradle  pessary. 


Fig.  179. — Graily-Hewitt's  pessary  mo- 
dified by  Courty,  so  as  better  to  main- 
tain the  reduction  of  the  retroflexion. 


does  not  hinder  the  accomplishment  of  any  function,  not  even  of 
coitus. 

Lastly,  there  are  pessaries  which  have  an  external  as  well  as  an 
internal  poi7it  d'appui.     The  external  fulcrum  varies.     It  may  be  the 


METHODS    OF    TREATMENT    AND    MEDICATIONS 


199 


straps  which  pass  under  the  thighs  crossing  at  the  vulva  (I'ig.  181),  in 
which  case  it  is  distributed  to  the  four  opposite  points  of  the  belt, 


GALANTe 


Fig.  180.— Cup-and-ball 
pessaiy  having  an  ex- 
ternal fulcram. 


Fig.  181.  —  Bourjeaurd's  air  pessary, 
supported  by  india-rubber  straps 
crossingf  under  the  vulva. 


which  is  onlj  the  more  firmly  fixed  for  being  drawn  downwards  by  the 
tendency  of  the  uterus  to  prolapsus.  It  may  be  the  plate  of  a  hypo- 
gastric belt  (Fig.  182),  an  arrangement  which  is  much  better  for  the 
patient,  but  which  requires  more  skill  in  the  construction. 


Fig.  182. — Roser's  hysterophore,  modi- 
fied by  Scanzoni  and  Charriere. 


Fig.  183. — Scanzoni's  pessary 
with  ball-and-socket  joint. 


The  internal  fulcrum  varies  also.  Sometimes  it  is  the  vagina,  the 
anterior  cul-de-sac  being  supported  against  the  pubis,  so  as  to  raise  at 
the  same  time  all  the  rest  of  the  organ  and  the  uterus  itself,  unless 
there  be  great  relaxation  of  the  posterior  wall,  rectocele,  retroversion, 
&c.  (Figs.  182,  183).  Sometimes  it  is  the  cervix  which  is  directly 
supported  by  means  of  an  india-rubber,  ivory,  or  metallic  ring  (Figs. 
180,  181).  The  only  means  of  making  this  pessary  bearable  is  to 
adapt  a  system  of  elastic  articulations  or  supports  to  its  stem,  which 
allow  free  movement  to  the  patient  without  danger  of  displacing  the 
pessary  or  causing  pain. 

3.  Intra-uterine  mechanical  sxipports  are  also  known  by  the  name  of 
redressors ;  that  of  uterine  director,  however,  would  be  more  correct. 
The  first  and  I  think  the  best  (Fig.  181)  of  these  instruments  was 
invented  by  Simpson.  It  is  a  hollow  metallic  stem  Cgeuerally  made  of 
two  dififerent  metals  in  order  to  produce  a  current  of  electricity),  and 


200        TEEATMENT    OF    UTERINE    DISEASES   IN    GENERAL 


terminates  in  a  hollow  bulb ;  tbe  stem  is  introduced  into  the  uterus, 
the  bulb  remaining  in  the  vagina  where  it  is  kept  in  position  by  a  large 


Fig.  184. — Simpson's  intra-uterine  stem 
pessary  or  galvanic  director. 


Fig.  185. — Stem  pessary  of  alumi- 
nium for  dilating  the  os. 


tampon  saturated  with  glycerine.  It  is  made  of  various  sizes  in  order  to 
serve  as  a  dilator  in  cases  of  constriction  (Pig.  185).  This  instrument 
has  the  advantages  of  not  straightening  the  uterus  violently,  of  acting 
on  the  flexion  without  acting  on  the  version  at  the  same  time,  and  of 
leaving  the  uterus  mobile,  thus  avoiding  irritation  of  this  organ  or  the 
surrounding  parts,  which  are  more  frequently  inflamed  than  we  imagine. 
Kiwisch  invented  an  intra-uterine  stem  pessary  composed  of  two 
branches,  which  opened  after  being  introduced,  and  so  fixed  it  more 
firmly  in  the  uterus.  In  order  to  fix  it  more  firmly  in  the  vagina 
Detschy  associated  it  with  a  hysterophore,  whilst  Yalleix  attached  it  to 
an  external  support.  All  these  professed  improvements  have  only 
created  new  dangers  which  have  led  to  its  proscription.  In  order  to 
introduce  it  anew  and  to  procure  from  it  ail  the  benefits  that  it  alone 
can  give,  I  have  had  on  the  contrary  to  free  it  from  all  these  pre- 
tended aids  and  reduce  it  to  its  simplest  form. 

II.  Topical  remedies. — Before  describing  local  remedies  and  the 
way  of  applying  them,  I  must  not  omit  to  mention  the  best  kind  of 
forceps  for  making  such  applications.  Those  which  I  use  have  short 
blades,  and  are  consequently  very  strong  and  useful  for  dilating  the 
uterine  orifice ;  they  are  straight  or  curved,  and  grooved  so  as  to  hold 
a  needle  or  crush  the  pedicle  of  a  polypus,  with  a  catch  or  screw  near 
the  handles  to  graduate  the  pressure. 

Tojoical  remedies  are  solid,  liquid,  or  gaseous. 

1.  Among  solid  applications  I  give  the  first  place  to  tampons  of 
cotton  wool  or  lint,  and  to  the  little  operation  of  plugging,  which  must 
be  done  in  a  methodical  manner,  whether  it  be  to  arrest  a  haemorrhage 
or  to  maintain  various  medicaments  in  contact  with  the  cervix,  or  to 
prevent  the  cervix  from  coming  in  contact  with  the  vagina,  or  the  op- 
posite walls  of  this  canal  from  touching. 


METHODS    OP    TREATMENT    AND    MEDICATIONS 


201 


It  has  lately  been  proposed  to  substitute  for  plugging  with  lint  or 
cotton  wool  the  introduction  of  an  india-rubber  bag  (GarieFs  pessary), 
which  is  to  be  distended  with 
air  or  cold  water  when  in  the 
vagina;  but  the  use  of  this 
pessary  is  painful,  it  does  not 
allow  of  the  convenient  appli- 
cation of  medicines,  and,  more- 
over, it  is  not  always  at  hand 
like  cotton  or  lint.  I  also  find  it 
inconvenient  to  plug  by  means 
of  a  compress  previously  intro- 
duced into  the  vagina,  and 
serving  as  a  receptacle  for  the 
cotton ;  because,  whatever  may 
be  said,  it  is  not  possible  to 
withdraw  all  at  the  same  time ; 
that  is,  if  the  plugging  has 
been  sufficient  to  distend  the 
vagina. 

The  simplest  and  most  effi- 
cient way  is  the  following  :  The 
vagina  having  been  cleared  of 
the  clots  it  contains,  and  washed 
with  cold  water  or  an  astrin- 
gent liquid,  the  speculum  is 
introduced,  after  which  a  large 
pledget  of  lint  charged  with 
some  medicinal  substance  (alum, 
tannin,  perchloride  of  iron,  io- 
dine, or  any  caustic)  is  placed 
in  contact  with  the  cervix.  Af- 
terwards a  number  of  tightly 
rolled  balls  of  cotton  wool  are 
added,  which  by  means  of  long 
uterine  forceps  we  try  to  place 
in  the  farthest  corners  of  the 
vagina,  so  as  to  stretch  it  and 
to  surround  the  cervix.  Pajot^ 
tells  us  Dubois  proved  by  expe- 
riments that  pledgets  of  charpie 
mixed  with  pieces  of  agaric  are 
more  efficient  even  than  cotton 
in  opposing  an  insurmountable 
barrier  to  the  blood.  The  spe- 
culum is  gradually  withdrawn 

in  proportion  as  the  vagina  is  filled,  and  in  this  way  the  whole  space 
is  filled  by  a  multitude  of  little  pledgets  till  the  vulval  orifice  is 

'  Archives  generales  de  medecine,  fevrier,  1867. 


Fig.  186. — Conrty's  straight  uterine  for- 
ceps.     A,  the  same,  curved. 


202        TEEATMENT    OF    UTEEINE    DISEASES    IN    GENEEAL 

reached,  on  which  is  laid  a  larger  one,  supported  by  a  graduated  com- 
press firmly  fixed  by  a  T-bandage.  It  is  necessary  to  remove  some 
of  the  cotton  wool  a  few  hours  afterwards,  in  order  to  allow  of  the 
patient  passing  water  or  to  catheterise  her ;  the  next  day,  or  the  day 
after,  the  rest  is  removed  by  degrees,  care  being  taken  to  make  re- 
peated injections.  By  means  of  the  fingers  and  the  long  forceps  the 
greater  part  of  the  cotton  wool  is  easily  extracted ;  as  for  that  which 
is  in  contact  with  the  cervix  and  which  ought  to  be  left  a  little 
longer,  its  extraction  is  facilitated  by  frequent  injections  made  on  the 
bidet. 

When  the  plugging  is  intended  merely  to  maintain  a  medicament  in 
contact  with  the  cervix  it  may  be  reduced  to  two  tampons,  the  first 
applied  to  the  cervix  and  a  second  much  larger  one  to  keep  the  first 
in  position.  To  keep  the  vaginal  walls  from  touching  one  is  suffi- 
cient ;  this  may  be  charged  with  a  medicament  such  as  alum  or  tannin, 
or  it  may  be  saturated  with  a  solution  or  covered  with  an  ointment ;  or 
it  may  be  replaced  by  a  bag  containing  inert  powders  for  absorbing 
the  liquid  secretions,  or  medicated  powders,  emollients,  tonics  or 
astringents,  to  modify  the  diseased  surfaces  as  well  as  to  absorb  the 
secretions.  In  the  acute  stage  cataplasms  are  substituted  for  bags. 
Linseed  ferments  easily,  therefore  it  is  better  to  use  starch,  rice  or 
bread ;  glycerine  is  better  still.  Take  as  much  fine  cotton  wool  as  the 
hollow  of  the  hand  will  hold,  soak  it  in  tepid  water,  and  after  squeez- 
ing it  out  saturate  it  with  glycerine  and  introduce  it  into  the  vagina.-^ 
It  possesses  the  properties  of  absorbing  moisture,  disgorging  the  tissues 
with  which  it  is  in  contact,  and  of  being  in  some  degree  disinfectant. 
Lastly,  it  facilitates  the  absorption  of  medicines  mixed  with  it  under 
the  name  of  glyceroles.^ 

The  drawbacks  of  plugging  are  so  considerable  that  it  has  been 
proposed  to  substitute  for  it  the  introduction  of  inert  poivders  into  the 
vagina.  Eecamier  used  them  frequently,  Aran  also,  and  they  may 
always  be  resorted  to  when  there  is  an  indication  to  dry  the  vagina  by 
the  absorption  of  fluids  accumulated  in  its  cavity.  Starch  powder 
may  be  used,  or  lycopodium,  or  rice  flour  or  common  flour ;  starch  is 
most  frequently  used.  The  bivalve  speculum  is  introduced,  and  after 
aU  the  mucus  is  removed,  from  5J  to  5J  of  starch  powder  is  thrown 
into  the  cavity  of  the  instrument,  then  the  speculum  is  withdrawn,  and 
if  the  vulval  orifice  is  too  large  to  retain  the  powder  a  large  plug  of 
cotton  wool  must  be  introduced.  After  twenty-four  or  thirty-six  hours 
the  patient  makes  a  vaginal  injection  to  moisten  the  starch  and  bring 
it  away.  When  the  disease  is  at  the  vulva  it  is  sufficient  for  the 
patient  to  open  the  labia  and  powder  the  parts  exposed. 

Before  introducing  the  starch  it  may  be  moistened  with  laudanum 
or  some  other  medicament,  whichj  owing  to  the  starch  taking  the  form 
of  the  vagina,  is  kept  in  contact  with  the  parts  better  and  more  gently 
than  by  means  of  cotton.  I  do  not  contest  the  utility  of  this  application, 

1  Sims,  Clinical  Notes  on  Uterine  Surgery.     Loudon,  1866,  p.  70. 
?  Demarquay,  cle  la  Glycerine  et  de  ses  applications  a  la  chirurgie  et  a  la 
tnedecine,  2«  edit.     Paris,  1868. 


METHODS    OF    TEEATMENT    AND  MEDICATIONS  203 

but  I  am  not  in  favour  of  leaving  foreign  bodies  in  the  vagina  in 
contact  with  the  cervix  unless  in  exceptional  cases. 

Lastly,  in  place  of  inert  powders,  we  may  apply  oak  bark,  catechu, 
powdered  cinchona,  or  even  more  active  substances,  such  as  alum, 
tannin,  sulphate  of  zinc,  calomel,  bismuth,  &c.  As  a  rule  these  active 
substances  should  be  mixed  with  an  inert  powder  in  variable  propor- 
tions, according  to  the  effect  which  it  is  desirable  to  produce ;  or  they 
should  be  applied  in  the  centre  of  a  light  plug  of  cotton  wool.  One 
of  the  best  powders  for  modifying  diseased  surfaces  is  the  subnitrate 
of  bismuth. 

Plugging  hy  ice  has  been  recommended  by  Aran^  as  preferable  to 
the  refrigerating  mixtures  employed  in  cases  of  cancer  by  Arnott,  to 
whom  we  owe  various  experiments  on  the  ansesthetic  action  of  cold. 
It  consists  in  bringing  into  contact  with  the  cervix  a  greater  or  less 
quantity  of  ice  broken  into  little  bits,  which  may  either  be  simply  left  in 
the  vagina  or  may  be  renewed  as  it  melts.  In  both  cases  the  cervix 
is  exposed  by  means  of  a  speculum,  of  wood,  if  we  only  wish  to  act  on 
the  cervix  and  in  a  moderate  way,  of  metal,  if  we  wish  to  act  more 
energetically ;  the  quadrivalve  speculum  is  convenient  for  this  applica- 
tion. When  the  ice  is  not  to  be  renewed,  we  must  take  care  to  retain 
it  by  means  of  a  large  pledget  of  lint  introduced  when  the  speculum  is 
withdrawn  :  reaction  is  then  less  rapid  and  less  disagreeable.  The  refri- 
gerative  action  is  much  more  marked  when  a  metalhc  speculum  is  used  -, 
it  is  exercised  on  the  whole  of  the  vagina  as  well  as  on  the  cervix. 
With  the  exception  of  temporary  colic  in  the  abdomen  anaesthesia  is 
complete  in  a  few  minutes  j  by  continuing  the  application  of  ice  from 
a  quarter  of  an  hour  to  an  hour  the  action  exercised  on  the  circulation 
and  sensibility  of  the  pelvic  organs  may  be  so  great  for  several  hours 
as  to  lead  patients  to  think  they  have  been  freed  from  all  their  troubles, 
and  to  allow  of  their  walking  and  attending  to  their  various  duties. 
Aran  said  that  the  reaction  was  insignificant;  he  renewed  the  applica- 
tion every  day  or  every  two  days  eight  or  ten  times  in  the  course  of 
treatment. 

Whilst  admitting  that  plugging  with  ice  may  be  of  great  use  in 
cases  of  hsemorrhage,  cancer,  hyperaesthesia,  neuralgia,  inflammation 
and  congestion,  in  which  it  was  especially  used  by  Aran,^  I  must  say 
that  the  indication  for  it  has  never  seemed  to  me  so  marked  as  to  lead 
me  to  have  recourse  to  it.  It  cannot  be  denied  that  it  exposes  the 
patient  to  too  energetic  reactions,  and  that  it  is  an  inconvenient  appli- 
cation, as  well  as  being  sometimes  impossible,  from  the  difficulty  of 
getting  ice.  In  most  cases  cold  irrigations  with  refrigerating  applica- 
tions to  the  abdomen  are  sufficient. 

Paint'mg  the  cervix  with  collodion. — Mitchell^  has  introduced  this 
means  as  a  substitute  for  nitrate  of  silver  in  the  treatment  of  ulcera- 
tion of  the  cervix.  This  organ  having  been  wiped,  collodion  is  applied 
with  a  camel's  hair  brush ;  twenty  minutes  is  allowed  for  the  medicine 

'  Op.  cit.,  p.  220. 

2  Ibid.,  p.  379. 

^  Dublin  Medical  Press,  October,  1848. 


204        TREATMENT    OF    UTERINE    DISEASES    IN    GENERAL 

to  dry,  and  one  or  two  additional  layers  are  then  applied  in  the  same 
way.  This  application  must  be  renewed  in  forty-eight  hours  because 
the  secretion  which  accumulates  under  this  varnish  detaches  it.  In 
the  case  of  simple  abrasion,  three  applications  were  sufficient.  If  the 
disease  is  more  obstinate,  if  there  are  large  granulations,  this  physician 
uses  in  the  first  instance  nitrate  of  silver,  acid  nitrate  of  mercury,  or 
solution  of  caustic  potash,  applying  the  collodion  above. 

I  think  that  the  application  of  collodion  ought  to  be  confined  to 
two  kinds  of  cases :  elastic  collodion  for  very  superficial  erosions  and 
excoriations  of  the  cervix ;  pure  collodion  in  cases  of  engorgement  or 
oedema  to  obtain  a  reduction  in  bulk  of  the  organ  under  the  influence 
of  the  contraction  which  the  collodion  undergoes  in  drying. 

The  majority  of  solid  medicated  topics  are  ointments,  varying  in 
consistency  from  that  of  suppositories  to  almost  liquid  preparations. 

Vaginal  suppositories,  like  suppositories  introduced  into  the  rectum, 
were  used  by  the  ancients  in  remote  times.  Their  use  has  been  revived  by 
Simpson  under  the  name  of  medicated  pessaries.  They  are  conical,  cylin- 
drical, or  ovoid,  the  latter  being  the  best  form  for  enabling  the  patient 
to  push  them  to  the  farthest  end  of  the  vagina,  and  also  for  increasing 
the  chance  of  retention.  In  size  they  must  not  exceed  one  inch  in  length 
by  half  an  inch  in  width.  They  are  made  of  wax  and  lard  or  cacao  butter 
in  suitable  proportion  to  give  them  a  proper  consistency ;  they  contain 
a  certain  quantity  of  some  medicinal  substance,  sedative,  astringent, 
or  resolvent ;  such  as  mercurial  ointment,  iodide  of  lead,  extract  of 
belladonna,  &c.  The  patient  introduces  them  into  the  vagina  in  the 
evening,  pushing  them  back  as  far  as  possible ;  they  melt  in  a  few 
hours,  and  a  tepid  injection  made  the  following  morning  removes 
whatever  has  not  been  absorbed.  We  must  not  count  too  much  on 
the  action  of  these  pessaries ;  in  the  first  place  they  do  not  always 
melt  well  however  carefully  they  have  been  made;  in  the  second 
place  the  power  of  absorption  of  the  vaginal  mucous  membrane  is  not 
great,  especially  for  oily  bodies.  When  rapid  and  energetic  action  is 
desirable,  whether  sedative  or  resolvent,  it  is  better  to  introduce  them 
into  the  rectum.  The  ointments  which  I  use  most  frequently  are  the 
ordinary  mercurial  ointment  with  the  addition  of  a  tenth  part  of  the 
extract  of  belladonna,  or  ointments  containing  calomel,  red  oxide  of 
mercury,  iodide  of  lead,  potassium,  &c.  I  apply  them  to  the  cervix 
simply  on  a  pledget  of  cotton  wool  and  withdraw  the  speculum,  or  I 
put  a  thick  layer  of  ointment  on  a  little  round  mat  of  coarse  thread, 
the  size  of  the  cervix,  which  the  patient  could  crochet  or  knit  in  a  few 
minutes,  and  which  forms  a  little  cup  for  holding  the  uterus.  I  apply 
this  to  the  cervix,  keeping  it  in  position  by  means  of  a  large  pledget 
of  cotton  wool. 

When  it  is  necessary  to  make  applications  to  the  uterine  cavity  I 
use  special  instruments,  which  I  wUl  afterwards  describe  along  with 
intra- uterine  caustic  holders. ^ 

2.  Liquid  applications  are  easily  applied  to  the  cervix  and  vagina. 

»  See  p.  336. 


METHODS    OF    TREATMENT   AND    MEDICATIONS  205 

I  often  use  them  to  modify  the  vaginal  surface  in  place  of  prescribing 
injections  or  lotions  for  the  patient.  After  having  cleansed  the  vagina 
it  is  easy  to  apply  a  liquid  to  the  whole  of  its  surface  by  means  of  a 
brush  whilst  the  speculum  is  being  withdrawn.  In  this  way  great 
effect  is  produced,  and  we  are  surprised  to  see  vaginal  leucorrhoea,  ero- 
sions, even  ulcers  cured  in  a  few  days  or  a  few  weeks,  which  had  been 
treated  for  months  past  by  injections  without  any  result  having  been 
produced.  There  are  various  modes  of  applying  liquids :  sometimes 
the  medicament  is  poured  into  the  speculum  followed  by  an  inert 
powder  which  absorbs  it  and  forms  a  magma  round  the  cervix.  When 
the  action  is  to  be  limited  to  the  cervix  it  is  poured  into  the  speculum, 
and  after  being  left  in  contact  with  the  cervix  allowed  to  escape  by 
lowering  the  speculum;  or  it  may  be  applied  by  means  of  a  pledget  of 
lint  or  a  cameFs  hair  brush.  When  caustics  are  used  the  surface 
touched  should  generally  be  washed  as  soon  as  the  desired  action  has 
been  produced  and  before  withdrawing  the  speculum.  The  liquids 
most  frequently  used  are  sedatives,  astringents,  solvents,  stimulants, 
cathartics.  Laudanum  is  useful  not  only  as  a  sedative  but  to  induce 
cicatrisation.  Solutions  of  alum  and  tannin  may  be  applied  by  means 
of  a  large  brush  to  the  whole  of  the  utero-vaginal  mucous  membrane. 
The  other  liquid  astringents  are  solutions  of  acetate  of  lead,  solutions 
of  peroxychloride  of  iron,  ddute  tincture  of  iodine,  &c.  The  principal 
cathartic  liquids,  which  may  be  either  resolvent  or  stimulating,  are : 
tincture  of  perchloride  of  iron,  especially  in  cases  of  diphtheria,  a 
saturated  solution  of  chlorate  of  potassium,  pure  tincture  of  iodine, 
iodoform,  a  solution  of  corrosive  sublimate,  and  above  all  the  solu- 
tion of  nitrate  of  silver,  or  a  cameFs  hair  brush  dipped  in  water  and 
then  applied  to  the  solid  crayon  may  be  used.  Several  of  these  liquids 
may  be  advantageously  used  mixed  with  glycerine.  Glycerine  as  an 
emollient  may  be  employed  alone  in  cases  of  erosions  and  superficial 
ulceration.  There  are  very  few  of  these  substances  which  do  not  affect 
metal;  therefore,  as  a  rule,  I  use  a  wooden,  glass,  or  gutta-percha 
speculum  for  all  liquid  applications.  When  irritant  or  caustic 
liquids  are  used  care  must  be  taken  to  remove  with  a  little  cotton 
wool  all  that  may  remain  on  the  cervix  or  vagina,  lest  it  should 
touch  the  lower  part  of  the  vagina  or  the  vulval  orifice  which  are 
extremely  sensitive. 

Lastly,  it  must  be  remembered  that  however  important  local  treat- 
ment may  be  it  must  not  be  abused,  especially  with  patients  who  do 
not  tolerate  it  easily. 

3.  The  only  gaseous  applications  that  have  been  used  in  the  treat- 
ment of  uterine  diseases  are  chloroform  and  carbonic  acid.  Carbonic 
acid  was  first  used  as  a  local  anaesthetic  by  Ingenhousz.  In  1884 
E/Ozier  injected  it  into  the  vagina  of  women  suffering  from  cancer  of  the 
uterus;  it  was  also  recommended  by  Mojon  in  injections  to  alleviate 
pain  and  to  induce  the  catamenial  flow.  It  was  introduced  into  use 
in  Scotland  by  Simpson  and  into  France  by  Follin  and  Broca. 
Demarquay  and  Monod,  who  have  also  tried  it,  think  that  vaginal 
injections  of   carbonic  acid  produce  good  effects  when  the  mucous 


206 


TREATMENT   OP    UTERINE    DISEASES    IN    GENERAL 


membrane  is  denuded,  whilst  no  effect  is  produced  when  the  tissues 
are  whole. 

Different  apparatus  may  be  used :  the  simplest  is  an  ordinary 
bottle  furnished  with  a  conducting  tube  (Simpson);  but  the  most 
convenient  is  that  of  Fordos.  The  canula  is  first  introduced  into  the 
vagina,  then  the  apparatus  is  charged.  An  ounce  of  tartaric  acid 
in  large  crystals  is  first  put  into  the  carafe,  then  3  oz.  of  bi- 
carbonate of  soda  in  powder ;  half  a  pint  of  water  is  then  poured 
in  and  the  carafe  is  filled  up  with  a  tin  tube  containing  fragments 

of  marble  and  pieces  of  sponge, 
which  filter  the  gas  as  it  is  libe- 
rated, freeing  it  from  the  saline 
and  acid  particles  that  are  me- 
chanically swept  out.  By  satura- 
ting the  pieces  of  sponge  contained 
in  the  tin  tube  with  chloroform 
we  have  the  anaesthetic  action  of 
its  vapours  in  addition  to  that  of 
the  carbonic  acid,  and  we  avoid 
the  current  of  air  produced  in  the 
vagina  by  the  injection  of  chloro- 
form fumes  alone. 

Charles  Bernard^  has  mentioned 
cases  of  cerebral  accidents  caused 
by  these  injections ;  but  they  must 
happen  very  seldom,  and  do  not 
contra-indicate  the  use  of  this 
means.  A  more  serious  drawback 
is  that  carbonic  acid,  like  chloro- 
form, whilst  soothing  pain  pro- 
vokes congestion  of  the  diseased 
parts,  which  ought  to  lead  to  its 
rejection  in  cases  of  fluxion,  con- 
gestion and  metritis,  its  use  being 
reserved  for  hypersesthesia  and  ute- 
rine neuralgia. 

Chloroform  has  been  adminis- 
tered by  Hardy  (of  Dublin)  in 
vaginal  injections  in  the  form  of 
vapour.  The  apparatus  invented  by  this  surgeon  is  composed  of  a 
small  metallic  cylinder,  in  which  is  placed  a  sponge  saturated  with 
chloroform.  A  tube  is  adapted  to  one  extremity  of  this  cylinder, 
communicating  with  an  india-rubber  bag  distended  with  air.    Another 

^  ArcMv  gen.  de  med.,  5^  serie,  t.  x,  p.  529,  1857. 

Scanzoni,  Beitrdge  zur  Geburtskunde  und  Gyndhologie,  1858,  t.  iii,  p.  181, 
has  mentioned  a  case  of  death  after  the  injection  of  carbonic  acid  into  the  cer- 
vical cavity.  Death  took  place  in  one  hour  and  three  quarters.  It  made  a  great 
sensation  in  Grermany,  and  led  to  Breslau's  and  Vogel's  experiments  on  pregnant 
rabbits.  See  Wiener  medizinische  Woclienschrift,  11  Sept.,  1868.  The  Gazette 
hebdoofnadaire,  1858,  p.  741,  gives  an  abridged  account  of  the  article. 


Fig.  187. — Hardy's  india-rubber  in- 
sufflator   with    double   valve    and 


reservoir. 


METHODS  OF  TREATMENT  AND  MEDICATIONS      207 

tube  is  attached  to  the  other  extremity  of  the  cylinder,  termina- 
ting in  a  long  india-rubber  canula,  which  ought  to  reach  the  cervix 
when  introduced  into  the  vagina.  By  compressing  the  india-rubber 
bag  it  is  emptied  of  the  air  which  it  contains,  and  this  air  in 
passing  through  the  cylinder  is  charged  with  anaesthetic  fumes  which 
are  introduced  into  the  vagina  by  means  of  the  canula.  A  valve 
allows  the  re-admission  of  air  into  the  bag  from  which  it  is  again 
driven  through  the  cylinder.  This  apparatus,  with  slight  modifi- 
cations, has  also  been  utilised  for  the  insufflation  of  medicated 
powders  into  the  vagina  and  uterus,  but  it  is  better  to  use  a  camel's 
hair  brush. 

III.  Operations  are  of  two  kinds.  The  first  are  small  operations 
analogous  to  dressings,  only  differing  from  them  in  the  nature  of  the 
substances  used;  for  when  there  are  caustics  the  danger  incurred 
necessitates  great  care  and  prudence.  The  second  class  includes 
special  operations  for  special  diseases,  in  performing  which  the  obser- 
vance of  the  ordinary  rules  of  surgery  is  required.  I  will  describe  all, 
entering,  however,  into  more  minute  details  when  treating  of  those 
which  occur  most  frequently. 

The  posture  which  the  patient  ought  to  adopt  in  order  to  facili- 
tate the  different  operations  which  have  to  be  performed  on  the  uterus 
and  vagina,  with  or  without  speculum,  varies.  In  each  case  we  must 
take  care  to  resort  to  the  one  which  theory  and  practice  teach  us 
is  the  best.  These  postures  are : — 1,  Supination  on  the  back  as  for 
lithotomy ;  2,  lumbo-sacral  supination  (the  first  exaggerated),  so  as 
to  raise  the  vulva  more ;  3,  right  or  left  lateral  pronation ;  4,  pro- 
nation on  elbows  and  knees;  5,  pronation  on  the  edge  of  the  bed, 
the  feet  touching  the  ground,  the  chest,  head  and  arms  on  the  bed. 
The  three  last  postures  are  sometimes  very  convenient  after  dilatation 
of  the  vagina,  owing  to  the  introduction  of  air,  as  well  as  to  the 
projection  of  the  uterus  towards  the  hypogastrium  and  of  the  intes- 
tines towards  the  umbilicus.  This  projection  exposes  the  posterior 
vaginal  cul-de-sae  very  clearly,  and  the  horizontal  position  given  to 
the  cervix  is  favorable  for  applications. 

Most  of  these  operations  are  facilitated  by  the  use  of  tenaculum  hook 
forceps.  These  are  of  two  kinds: — 1.  The  converging  tenaculum 
forceps,  made  to  glide  so  as  to  seize  at  different  heights  the  part  re- 
quired to  be  held,  and  to  disarticulate  so  as  to  make  two  very  fine 
single  hooks ;  3.  the  diverging  tenaculum  forceps,  which  is  an  excellent 
instrument  of  prehension  and  distension. 

A.  General  operations. — The  small  operations  requiring  to  be  re- 
peated frequently  like  dressings  are :  the  application  of  electricity,  of 
the  actual  or  potential  cautery,  intra-uterine  injections,  &c. 

1.  Electricity  may  be  employed  as  a  sedative,  stimulant,  or  resol- 
vent. Under  the  form  of  the  continued  current  it  exercises  a  sedative 
action  on  the  uterus  as  on  other  organs  or  on  nerves  affected  with 
rheumatic  neuralgia.  Under  other  forms  it  stimulates  the  vitality  of 
the  tissue,  accelerates  absorption  in  cases  of  engorgement  and  hyper- 
trophy, excites  muscular  contraction,  thus  reducing  the  size  of  the 


208  TREATMENT    OF    UTERINE    DISEASES    IN    GENERAL 


congested    organ,  and  by  strengthening  the  relaxed   tissue    corrects 
flexions,  &c. 


Fig.  188.  Fig.  189. 

Fig.  188. — Converging  and  sliding  tenaculum  hook  forceps  :  a,  forceps  when 
shut;  B,  one  of  the  branches  of  the  forceps  open,  sliding  on  the  articula- 
tion ;  c,  one  of  the  branches  separated  from  the  other  serving  as  a  simple 
tenaculum  hook. 

Fig.  189. — Diverging  tenaculum  hook  forceps  :  a,  shut ;  B,  open. 

2.  Caute?'isation  of  the  cervix. — This  is  one  of  the  most  useful  and 
therefore  one  of  the  most  frequent  operations.  At  the  same  time  the 
indications  for  it  are  somewhat  difficult  to  determine,  for  it  may  be 
resorted  to  in  the  treatment  of  several  diseases.  It  is  not  surprising 
that  it  should  have  been,  and  still  is,  the  means  most  frequently 
abused. 

I  can  affirm,  as  the  result  of  long  experience,  that  when  suitably 
applied  it  renders  greater  services  perhaps  than  any  other  means  in 
the  treatment  of  uterine  diseases;  but,  on  the  other  hand,  when  em- 
ployed in  spite  of  certain  definite  contra-indications  very  commonly 
misunderstood,  and  especially  when  used  as  a  universal  panacea  for  all 
uterine  diseases,  it  has  done  as  much  harm  as  good,  in  aggravating  or 
perpetuating  a  number  of  maladies  which  would  have  been  cured  but 
for  it.  The  most  serious  consequences  are  the  producing  of  constric- 
tions and  obliterations  of  the  cervical  canal,  and  the  setting  up  of  sup- 


METHODS    OF    TREATMENT    AND    MEDICATIONS  209 

puration  from  its  application  when  applied  to  patients  suffering  from 
peri-uterine  inflammation  which  has  passed  unnoticed.  The  potential 
as  well  as  the  actual  cautery  may  be  used. 

Potential  cauterisation. — The  caustics  used  may  be  liquid  or  solid. 

The  liquid  caustics  most  frequently  used  are  the  acids^  especially  the 
acid  nitrate  of  mercury.  Next  to  it  we  may  place  the  perchloride  of 
iron,  the  tincture  of  iodine,  which  acts  as  a  caustic  when  applied  to 
bleeding  or  ulcerated  surfaces,  and  the  saturated  solutions  of  the  solid 
caustics,  which  may  be  either  catheretic  or  caustic,  according  to  the 
degree  of  saturation  and  the  condition  of  the  surface  to  which  they 
are  applied. 

The  acid  nitrate  of  mercury.^  recommended  by  Recamier  and  em- 
ployed by  Lisfranc  and  several  other  physicians  in  preference  to  other 
caustics,  has  been  in  very  general  use.  It  is  very  much  in  vogue  even 
now,  enjoying,  as  it  seems  to  me,  an  undeserved  reputation  among  the 
profession.  It  is  employed  in  cases  of  granulation  and  simple  ulcera- 
tion, pure  or  diluted,  according  to  the  indication.  A  brush  made  of 
lint,  or  a  small  piece  of  sponge  cut  in  the  shape  of  a  cone  is  applied  to 
the  ulcerated  surface.  Immediately  afterwards  cold  water  is  poured 
into  the  speculum  to  prevent  any  stray  drops  of  the  caustic  from 
spreading  in  the  vagina.  In  addition  to  the  drawbacks  which  it  has 
in  common  with  other  liquid  caustics,  it  has  another  which  alone 
should  cause  its  rejection  :  in  some  women  it  induces  an  inconvenient 
and  obstinate  salivation. 

This,  although  at  first  disputed  by  some  writers,  is  now  an  esta- 
blished fact.  Therefore  I  prefer  nitric,  sulphuric,  hydrochloric  and 
chromic  acids,  pure  or  diluted  with  water,  in  variable  proportions,  or 
alkaUne  solutions,  like  potash,  creasote,  or  better  still,  perchloride  of 
iron,  the  saturated  solution  of  nitrate  of  silver  or  tincture  of  iodine. 
These  last  named,  however,  are  catheretic  rather  than  caustic.  When 
real  liquid  caustics  are  used  care  must  be  taken  to  wipe  the  wet  brush 
before  applying  it,  so  that  only  the  part  requiring  to  be  cauterised  may 
be  acted  on  and  not  the  surrounding  tissue. 

But  whatever  precautions  are  taken,  liquid  caustics  will  always  have 
two  serious  drawbacks.  1.  It  is  difficult  to  determine  the  depth  to 
which  they  penetrate.  2.  It  is  still  more  difficult  to  prevent  them 
from  spreading  beyond  the  point  desired  and  to  be  certain  that  the 
healthy  surfaces  will  escape  their  action.  Therefore  I  have  almost  given 
up  using  them,  only  em])loying  catheretics,  which,  infiltrating  all  the 
sinuosities  of  a  denuded  or  ulcerated  surface,  help  cicatrisation.  In 
all  cases  where  cauterisation  is  necessary  I  have  recourse  to  the  actual 
cautery,  or  to  a  solid  caustic  like  canquoin,  or  any  other  that  is 
deliquescent  or  pulverulent. 

Of  solid  caustics  canquoin  is  one  of  those  I  use  most  frequently.  I 
do  not  understand  Gendrin's  preference  for  the  Vienna  paste;  its 
advantages  ought  to  be  great  to  compensate  for  the  difficulties  in 
applying  it.  It  is  true  that  these  difficulties  are  overcome  in  the  ])re- 
paration  made  by  Tilhos ;  but  even  with  it  there  is  great  uncertainty 
as  to  the  extent  and  depth  of  the  scar,  besides  the  necessity  of  using 


210         TEEATMENT    OP    UTEEINE    DISEASES    IN    GENEEAL 

quantities  of  water  in  washing  the  surfaces,  and  the  possibility  that  in 
spite  of  all  precautions  some  of  the  caustic  may  remain.  All  these 
disadvantages  present  such  a  striking  contrast  with  the  simplicity  of 
the  actual  cautery,  that  in  spite  of  the  high  authority  of  Gendrin's 
practice  and  of  Henry  Bennetts  recommendation,  I  cannot  understand 
how  the  use  of  Pilhos's  caustic  has  come  to  be  adopted.  Besides,  we 
know  that  all  these  alkaline  caustics  produce  soft  scars,  make  the  blood 
diffluent,  and  induce  haemorrhage.^ 

Therefore  when  I  find  that  the  actual  cautery  will  not  produce 
sufficiently  deep  scars,  especially  on  hard,  friable,  bleeding  tissues,  like 
cauliflower  excrescences,  and  that  it  is  not  followed  by  that  modifica- 
tion of  the  surrounding  surfaces  which  seems  to  be  effected  by  certain 
caustics,  I  never  have  recourse  to  any  other  caustic  than  chloride  of 
zinc,  so  highly  recommended  by  Bonnet,  of  Lyons,  and  which  I  had 
previously  used  repeatedly  with  success.     Chloride  of  zinc  hardened 
with  a  variable  quantity  of  flour  and  spread  on  linen  in  layers  of  vary- 
ing thickness  forms  what  is  called  canquoin  plaster,  its  caustic  strength 
depending  on  the  relative  quantity  of  the  chloride  and  on  the  thick- 
ness of  the  layer  of  paste.    Nothing  is  easier  than  to  cut  a  little  circle 
of  this  plaster  and  place  it  on  the  cervix,  or  to  roll  it  up  and  introduce 
it  into  the  ragged  cavity  of  the  cancerous  organ,  or  to  cut  it  in  small 
arrows  to  be  inserted  into  the  tumour,  according  to  Maisonneuve's 
plan,  keeping  it  in  place  by  plugging.     This  is  the  least  painful  and 
least  dangerous  mode  of  applying  this  caustic.     If  the  piece  of  plaster 
is  not  very  thick,  and  if  the  portion  of  the  organ  which  has  to  be 
destroyed  is  considerable,  the  application  may  be  left  for  twenty-four 
hours,  otherwise  it  may  be  removed  in  a  few  hours.     Copious  injec- 
tions  of  tepid  water   must   then   be  made,  after  which  it  may  be 
advisable  to  introduce  tampons,  either  dry  or  covered  with  cold  cream, 
at  least  into  the  farthest  extremity  of  the  vagina,  to  prevent  any  frag- 
ments of  the  causlic  that  may  be  softened  and  brought  away  by  the 
suppuration  from  destroying  the  corresponding  part  of  the  vaginal 
walls.     I  have  frequently  seen  considerable  destruction  of  the  vagina 
result  from  an  awkwardly  made  application  of  this  caustic,  which  is 
really  dangerous  in  inexperienced  hands.  When  the  scar  falls  a  second 
application  can  be  made  when  necessary. 

I  often  use  dehquescent  chloride  of  zinc,  over  which  I  pass  a  wet 
cameFs-hair  brush,  which  is  then  applied  to  the  parts  needing  cauteri- 
sation. At  other  times  I  have  recourse  to  Rousselot^s  red  arsenical 
powder,  or  that  of  Friar  Come,  which  is  better  still.  It  contains  more 
arsenic,  and  is  as  efficacious  in  ulcers  of  the  cervix  as  in  those  of  the 
face,  to  which  it  is  generally  applied. 

Chromic  acid  is  also  a  valuable  caustic,  provided  it  is  not  applied 
over  too  extensive  a  surface,  so  as  to  produce  poisoning  characterised 
by  vomiting. 

Nitrate  of  silver,  which  is  the  most  used  of  all,  is  not  essentially 
destructive.     It  acts  as  a  simple  modificator  when  used  in  solution ;  as 
catheritic  when  a  wet  brush  is  saturated  with  this  salt  by  being  passed 
'  Philippeaux,  Traite  pratique  de  la  cauterisation.     Paris,  1856. 


METHODS    OF    TREATMENT    AND   MEDICATIONS 


211 


over  the  crayon  several  times ;  as  a  protector  of  the  ulcerated  surfaces 
by  the  coagulation  of  mucus  and  the  precipitation  of  chloride  of  silver 
acting  almost  in  the  same  way  as  collodion ;  in  repressing  exuberant 
granulations  when  the  crayon  is  applied.  Lastly,  in  modifying  as  well 
as  destroying  tissue  when  the  powder  or  crayon  is  left  in  the  uterine 
cavity,  a  method  to  which  I  will  afterwards  refer  when  treating  of 
intra-uterine  cauterisation. 

The  actual  cautery. — It  is  specially  suitable  as  an  application  to  the 
cervix,  for  this  organ  is  almost  insensible  to  the  action  of  fire — at  least 
to  the  pain  which  this  action  produces  on  other  tissues. 

There  is  no  better  mode  of  applying  fire  to  diseased  surfaces  than 
by  means  of  red-hot  iron. 

Although  this  means  has  been  employed  for  long,  it  has  probably 
never  been  used  with  method  and  discrimination  till  our  own  time. 
Larrey^  gave  all  the  necessary  operative  details,  but  it  was  Jobert^s^ 
works  that  popularised  this  operation  in  gynecological  practice.  As  I 
believe  that  additional  information  on  this  subject  would  be  welcomed, 
I  will  relate  what  a  long  practice  has  taught  me. 

Several  kinds  of  cautery  are  necessary,  according  to  the  use  for 
which  they  are  intended.  I  use  two  kinds  especially ;  the  first  are 
very  fine,  with  a  reservoir  for  heat  for  ignipuncture ;  the  others  spear- 


FiG.  190. — Cauteries  for  ignipuncture. 

shaped,  straight  or  curved,  for  ignilysis  or  section  by  fire.     I  have  also 
conical  cauteries  of  every  size  down  to  that  of  a  grain  of  corn,  others 


Fig.   191. — Cauteries   for   scarifications,   sections   and   excisions    by    fire.      d, 

straight  ;  E,  curved. 

cylindrical,  nummular,  &c. ;  I  even  had  a  cup-shaped  one  made  for 

'   Clinique  cMrurgicale,  t.  ii,  pp.  114,  829.     Paris,  1830 — 183G. 

"  Plaies  d'armes  a  feu,  Memoire  sur  la  cauterisation.    Paris,  1833. 


212         TEEATMENT    OF    UTERINE    DISEASES    IN    GENERAL 

destroying  an  irreducible  inverted  uterus,  and  I  used  it  afterwards  for 
cauterising  a  cervix  enormously  engorged  or  hypertrophied.  I  have 
found  nothing  better  for  heating  the  cauteries  than  the  eolipile 
spirit  lamp  which  solder ers  generally  use.  I  think  this  lamp  and 
these  cauteries  are  to  be  preferred  for  this  purpose  even  to  the  thermo- 
cautery, although  I  admit  the  superior  advantages  of  the  latter  in 
other  circumstances. 

The  operation  of  cauterisation  is  performed  in  the  following  man- 
ner: after  introducing  a  speculum  of  wood  or  of  glass,  the  uterus  is 
seized  firmly  and  the  speculum  pressed  against  it  so  that  it  cannot 
escape,  the  operator  being  on  his  guard  against  any  movements  that 
the  patient  may  make;  the  cervix  is  then  well  wiped  with  cotton 
wool ;  if  it  is  bleeding  the  cotton  ought  not  to  be  withdrawn  till  an 
assistant  has  brought  the  cautery,  which  must  be  at  white  heat. 
Whilst  the  left  hand  holds  the  speculum  the  right  apphes  the  cautery 
to  the  uterus,  and,  according  to  the  object  in  view,  the  uterus  is  barely 
touched,  or  the  iron  may  pass  lightly  over  different  points  of  its  sur- 


FiG.  192.— Eolipyle  spirit  lamp  for  heating  cauteries. 

face,  or  may  be  left  in  contact  with  some  point  for  a  few  instants,  and 
when  necessary  be  replaced  by  a  second  cautery ;  or,  lastly,  it  may 
even  be  introduced  into  the  cervical  cavity,  care  being  taken  to  pro- 
tect the  healthy  part  by  one  of  Eecamier's  large  curettes.  In  most 
cases,  however,  the  operation  is  much  simpler,  being  limited  to  one  or 
more  punctures  varying  in  depth  from  5  to  15  millimetres,  in  one  or 
other  of  the  lips  of  the  cervix.  At  other  times  excision  of  the  diseased 
part  may  be  performed  by  making  use  of  a  univalve  in  place  of  a 
cylindrical  wooden  speculum,  and  fixing  the  cervix  by  means  of  fine 
tenaculum  hook  forceps. 


METHODS    OF    TREATMENT  AND    MEDICATIONS 


21; 


Immediately  the  cautery  is  withdrawn  cold  water  should  be  poured 
into  the  speculum  several  times ;  this  instrument  may  then  be  with- 
drawn, when  the  patient  is  placed  in 
bed  in  the  dorsal  decubitus  with  legs 
and  thighs  flexed.  Cooling  applications 
may  be  made  to  the  hypogastrium, 
vulva,  and  upper  part  of  the  thighs, 
of  vinegar  and  water,  the  ice-bag,  &c. 

Serious  accidents  may  happen  affer 
cauterisation.  They  rarely  occur  unless 
the  patient  is  suifering  from  metritis, 
ovaritis  or  perimetritis.  However,  the 
freedom  from  pain  during  the  operation, 
the  superficial  action  of  certain  slight 
cauterisations  and  the  absence  of  trou- 
blesome consequences  after  imprudences 
committed  by  some  patients  subsequent 
to  this  operation,  have  inspired  some 
practitioners  with  too  blind  a  confidence 
in  the  innocuous  nature  of  this  means, 
and  a  blameable  temerity  in  its  use.  I 
have  seen  patients  who  had  actually 
been  cauterised  by  a  doctor  in  his  con- 
sulting room  !  I  have  also  seen  the  de- 
plorable consequences  of  such  impru- 
dence. Although  the  cervix  is  not 
sensitive  to  pain,  there  is  none  the  less 
a  reaction  after  the  traumatism  that  has 
been  undergone.  An  inflammation 
of  elimination  is  necessarily  developed 
round  the  scar;  this  inflammation  if 
neglected  may  pass  the  limits  within 
which  it  ought  to  be  confined,  and  ori- 
ginate very  serious  pathological  pheno- 
mena. Therefore,  in  order  to  avoid 
all  accidents  every  possible  precaution 
should  be  taken,  not  only  by  avoiding 
cauterisation  even  with  nitrate  of  silver 
during  the  week  preceding  the  cata- 
menia,  but  also  by  insisting  on  the 
patient  remaining  in  bed  for  several 
days,  the  hypogastrium  being  covered 
with  cooling  or  emollient  applications. 
She  should  take  an  emollient  bath  every 
day,  remaining  in  it  for  an  hour  at  least, 
and  making  vaginal  injections  all  the 
time ;  or  if  this  cannot  be  done,  vaginal 
irrigations  should  be  made  several  times 
a  day  with  some  disinfectant.     Thanks  to  these  precautions,  I   have 


Fig.  193. — Ignipnnctnro  of 
the  cervix,  which  is  kept 
fixed  by  the  divers^ing 
tenaculum  hook  forcep.s. 


214 


TEEATMENT  OF    UTEEINE    DISEASES   IN    GENERAL 


never  seen  any  accident  follow  the  numerous  cauterisations  I  have 
performed,  but  on  the  contrary  they  have  always  produced  good 
results. 

When  the  cervix  is  very  much  engorged  or  when  considerable  folli- 
cular hypertrophy  exists,  I  follow  the  excellent  advice  given  by 
Huguier,  making  a  number  of  scarifications  before  cauterising. 

The  cervix  may  be  cauterised  even  during  pregnancy  if  the  precau- 
tions are  taken  which  I  have  just  detailed.  I  need  hardly  say  that 
the  redhot  iron  is  not  to  be  applied  to  the  cervix  of  a  pregnant 
woman  who  is  merely  suffering  from  simple  granulations,  not  exceed- 
ing the  limits  often  assumed  by  this  morbid  condition  during  preg- 
nancy, and  giving  no  cause  to  fear  a  miscarriage.  When,  however, 
the  cervix  is  seriously  affected  recourse  may  be  had  to  cauterisation 
without  misgiving;  the  operation  being  practicable  from  the  end  of 
the  first  month  to  the  end  of  the  sixth.  There  need  be  no  anxiety  as 
to  causing  abortion ;  on  the  contrary,  one  of  the  advantages  of  this 
little  operation  in  such  a  case  is,  that  it  increases  the  chances  against 
the  occurrence  of  this  accident.^  Eacts  have  proved  to  me  not  only 
the  immunity  of  the  actual  cautery,^  but  also  that  its  application  in 


Fig  194. — Apparatus  for  cauterising  with  gas. 

the  case  of  pregnant  women  is  followed  in  due  time  by  a  safe  and 
normal  delivery.^ 

1  Mauny  has  puhlished  five  cases  of  persistent  vomiting  during  pregnancy, 
cured  by  cauterisation  of  the  cervix  with  nitrate  of  silver  or  with  acids. 
Paris,  1869. 

2  Annales  cliniques  de  Montpellier,  25  aout,  1853. 

3  Ibid.,  10  avril,  1854. 


METHODS    OF   TREATMENT    AND    MEDICATIONS 


215 


I  have  also  cauterised  the  cervical  cavity  when  its  mucous  mem- 
brane was  the  seat  of  follicular  or  granular  hypertrophy.  Great  care, 
however,  must  be  taken  to  cauterise  only  the  fungous  and  exuberant 
parts,  protecting  the  rest  from  the  action  of  the  heat.  Otherwise  we 
should  run  the  risk  of  causing  scars,  which  might  obliterate  or  at 
least  narrow  the  orifices,  as  unfortunately  too  often  happens. 

Nelaton  has  recommended  using  the  flame  of  a  gas-jet  in  place  of 
the  red-hot  iron.  The  advantages  of  this  cautery  are,  that  it  does  not 
frighten  the  patient,  who  need  not  even  be  aware  of  the  kind  of 
operation  about  to  be  performed;  it  allows  the  cauterisation  to  be 
defined  as  exactly  as  if  done  with  a  pencil,  and  above  all  it  permits  of 
a  more  energetic  action,  as  the  gas  flame  can  be  kept  in  contact  with 
the  diseased  part  as  long  as  necessary.  It  is  therefore  superior  to  the 
red-hot  iron  in  many  ways.  In  other  respects,  however,  it  is  inferior. 
It  only  acts  on  surfaces,  it  cannot  be  used  for  cauterising  the  cervical 
x;avity,  for  removing  an  excrescence,  for  scarifications,  nor  for  deep 


Fig.  195. 


Pig.  I'.M) 


Fig.  196. — Galvano-thermo-caustic  battery. 

Fig.  197. — g,  platinum  bistoury  ;  L,  cautery  in  fcirm  of  a  knife  ;    i\ 
cautery  ;  o,  cylindrical  cautery. 


216 


TREATMENT    OP    UTERINE    DISEASES   IX    GENERAL 


ignipunctureSj  which  in  my  opinion  are  the  most  useful  application 
that  can  be  made  of  the  actual  cautery  to  the  uterus. 

The  galvanic  cautery  is  applied  by  means  of  a  galvano-caustic 
handle  or  knife,  and  has  been  popularised  by  Middeldorpf.  Electro- 
lysis has  been  recommended  by  Ciniselli  and  adopted  by  some  sur- 
geonSj  who  consider  it  very  valuable ;  they  believe  that  in  performing 
a  section  by  means  of  the  negative  pole  around  which  the  alkaline 
elements  arrange  themselves,  the  scar  will  be  soft,  and  the  subsequent 
cicatrix  non-retractile  (which  remains  to  be  proved ;  in  my  opinion 
cicatricial  tissue  is  always  cicatricial  tissue,  i.e.  retractile).  The  diffi- 
culty of  keeping  galvanic  and  electrical  apparatus  in  order  will  always 
prevent  their  coming  into  general  use. 

Paquelin's  thermo-cautery  has  not  the  same  drawbacks.  At  my 
request  Collin  has  succeeded  in  making  spear-shaped  cauteries,  some 
curved  others  conical,  but  as  yet  he  has  not  been  able  to  make  any 
sufficiently  pointed  to  serve  for  ignipuncture  of  the  cervix.  This 
apparatus  though  much  simpler  than  electrical  machines  requires  con- 
siderably more  attention  than  the  eolipyle  lamp.  Therefore  this  lamp 
and  the  ordinary  cauteries  seem  to  me  preferable  to  all  other  instru- 
ments for  cauterising  the  uterus. 


Fig.  197. — Paquelin's  thermo-cauteiy. 

To  understand  the  harmlessness  of  the  actual  cautery  when  applied 
to  the  uterus  with  the  precautions  indicated,  we  must  remember  that 
the  fibro-plastic  nature  of  the  tissue,  the  tendency  to  hypertrophy,  the 
remarkable  facility  with  which  the  mucous  membrane  of  the  uterus  is 
renewed,  this  instability  of  a  tissue  which  I  have  described  as  being 
constantly  in  process  of  organisation,  must  greatly  facilitate  the  pro- 
cess of  repair  in  an  organ  like  the  uterus,  when  destruction  has  only 


METHODS    OF    TREATMENT   AND    MEDICATIONS  217 

extended  to  a  small  part  of  its  mucous  membrane,  and  especially  when 
this  destruction  has  been  limited  to  pathological  excrescences.  Not 
only  is  cauterisation  of  the  uterus  not  invariably  followed  by  the  for- 
mation of  a  cicatrix,  but  the  cauterised  cervix  which  previously  was 
hard  becomes  soft.  There  must,  therefore,  have  been  a  work  of 
absorption  going  on,  perhaps  the  production  of  new  elements ;  but 
not,  strictly  speaking,  the  formation  of  cicatricial  tissue.  There  is 
frequently  even  partial  renovation  of  the  mucous  membrane.  The 
oritice  is  the  only  part  we  must  always  treat  carefully. 

Only  a  short  time  since  I  had  a  new  proof  of  the  wonderful  facility 
with  which  repair  of  the  uterine  tissue  takes  place.  It  was  a  chronic 
case  of  complete  inversion  of  the  womb ;  reduction  was  impossible, 
and  it  seemed  to  me  that  the  only  indication  was  the  ablation  or  de- 
struction of  the  organ  by  the  actual  cautery.  The  ordinary  cauteries 
seeming  to  me  insufficient,  I  had  one  made  expressly  of  a  large  piece 
of  iron,  forming  therefore  a  much  larger  reservoir  of  heat  than  our 
largest  cauteries,  and  slightly  excavated  on  the  surface  so  as  to  mould 
itself  to  the  convexity  of  the  uterus.  I  applied  it  at  white  heat  to  the 
mucous  membrane,  leaving  it  long  enough  to  lead  me  to  hope  I 
had  effected  destruction;  but  with  the  exception  of  a  very  limited 
spot,  the  whole  of  the  mucous  membrane  resisted,  or  rather  was 
renewed  so  effectively,  that  after  making  fourteen  cauterisations  (which 
were  much  more  painful  than  those  of  the  cervix)  I  had  to  renounce 
further  attempts.  In  proportion  as  the  scar  was  detached  healthy 
granulations  appeared  underneath,  and  after  a  few  weeks  I  found  the 
surface  covered,  not  with  hard  and  retractile  cicatricial  tissue,  but  with 
a  soft  membrane  resembling  the  mucous  membrane  of  the  uterus  in 
appearance.  It  is  certain  that  the  red  hot  iron  does  not  produce  so 
deep  a  scar  as  one  would  think,  nor  as  that  caused  by  chloride  of 
zinc.  The  rapid  drying  of  the  surface  prevents  the  action  of  the  fire 
from  extending,  so  that  the  tissues  underneath  are  modified  rather 
than  destroyed. 

I  only  know  one  contra-indication  to  the  use  of  the  cautery,  whether 
actual  or  by  caustics,  and  that  is  the  e^^istence  of  inflammation,  and 
especially  of  peri-uterine  inflammation.  I  catinot  repeat  the  caution 
too  frequently  that  it  is  very  imprudent  to  cauterise,  especially  inter- 
nally, in  cases  of  parenchymatous  metritis,  and  even  of  inflammation  of 
the  mucous  membrane,  a  disease  all  the  more  dangerous  because  it  may 
simulate  a  simple  catarrh  or  be  coincident  with  it,  and  pass  unper- 
ceived  in  a  superficial  examination.  In  order  to  arrive  at  a  correct 
diagnosis  we  must  have  recourse  to  inspection,  touch  and  the 
uterine  sound ;  for  cauterisation  performed  in  such  circumstances 
has  led  to  serious  suppuration  in  the  uterus  and  its  appendages  ending 
in  death. 

At  present  I  am  attending  a  patient  suffering  from  serious  uterine 
and  peri-uterine  inflammation,  developed  after  an  inopportune  cau- 
terisation, made,  however,  by  a  Trench  surgeon  who  justly  enjoys  a 
great  reputation.  I  am  convinced,  from  knowledge  of  the  special 
antecedents  of  this  patient,  that  the  inflammation  existed  before  cau- 


2J8 


TEEATMENT    OF    UTERINE    DISEASES   IN    GENERAL 


terisation,  tliat  it  passed  unnoticed  because  the  patient  was  only  exa- 
mined with  the  speculum  unaided  by  touch  and  palpation,  and  that  it 
was  deplorably  aggravated  by  the  operation. 

The  scar  generally  falls  between  the  tenth  and 
fifteenth  day.  Cicatrisation  should  be  hastened, 
and  therefore,  besides  continuing  the  general  treat- 
ment of  baths,  irrigations,  and  (when  indicated) 
astringent  and  detersive  injections,  medicated 
applications  should  be  made  to  the  cervix  at 
variable  intervals.  I  may  mention  the  following 
as  particularly  useful :  laudanum,  when  all  that 
is  necessary  is  to  promote  the  natural  tendency  of 
the  wound  towards  cicatrisation;  the  solution  of 
nitrate  of  silver,  when  it  is  desirable  to  stimulate 
the  healthy  granulations ;  basic  peroxychloride  of 
iron/  when  the  wound  has  a  tendency  to  bleed, 
and  when  vascular  fungous  growths  seem  ready 
to  reappear  on  the  surface;  the  concentrated 
aqueous  solution  of  tannin,  or  even  the  crayons 
of  tannin  invented  by  Becquerel,  for  a  lesion  not 
extending  beyond  the  cervical  cavity,  when  the 
catarrhal  condition  and  aqueous  infiltration  seem 
to  have  caused  the  development  of  granulations 
(I  have  a  case  of  slight  catarrhal  granulations 
where  the  application  of  these  craj'ons  sufficed 
to  effect  a  cure) ;  iodoform  and  the  tincture  of 
iodine,  when  the  engorgement  of  the  cervix  and 
the  size  of  the  granulations  seem  to  indicate  a 
scrofulous  diathesis;  the  tincture  of  iodine  and 
the  perchloride  of  iron,  when  the  mucous  secretion 
is  very  abundant,  or  when  the  wound  is  pale  or 
diphtheritic,  and  requires  to  be  stimulated  or  mo- 
dified, or  when  it  threatens  to  bleed,  &c. 

3.  The  cauterisation  of  the  uterine  cavity  is 
performed  in  a  different  way.  Everything  here 
contra-indicates  the  use  of  energetic  caustics ; 
liquid  or  solid  caustics  cannot  be  blindly  applied 
to  diseased  parts  without  risk  of  causing  great 
injury;  the  red-hot  iron  must  not  on  any  account 
be  used,  it  would  burn  the  orifices  and  the  cervical 
walls  before  reaching  the  part  requiring  cauteri- 
sation ;  and  yet  we  cannot  doubt  the  existence  of 
fungosities  and  granulations  on  the  mucous  mem- 
brane of  the  body,  less  frequently,  but  still  as 
decidedly,  as  on  that  of  the  neck  ;  nor  can  we 
deny  that  the  means  which  succeed  best  in  the 
treatment  of  these  diseases  would  be  applicable 
to  the  mucous  membrane  of  the  body  as  well  as 
^  Montpellier  ^medical,  1858. 


do 


Fig.  198. 
Two  graduated  ute- 
rine sounds  of  dif- 
ferent calibre. 


METHODS    OF    TREATMENT    AND    MEDICATIONS 


219 


to  that  of  the  neck.  Leucorrhcea  itself,  a  morbid  condition  of  the 
glands  of  this  mucous  membrane,  seems  to  require  the  intervention 
of  active  applications.  Might  we  not  hope  that  astringents,  cathartics, 
caustics  would  effectually  help  the  action  of  general  treatment  as  well 
as  in  analogous  diseases  of  the  vagina  and  cervix  ?  This  conviction 
has  suggested  the  idea  of  applying  liquid  modifications  and  even 
caustics  by  means  of  injections. 

The  intra-uterine  injections  practised  by  Melier,  Yidal  (of  Cassis),^ 
Scanzoni  and  Aran,  and  met  with  disapproval  by  Hourmann,  Nonat, 
&c.,  must  be  ranged  among  the  most  energetic  means  of  modifying 
the  tissues,  but  also  the  most  dangerous  that  can  be  employed,  if  not 
practised  according  to  the  rules  about  to  be  laid  down. 

We  must  begin  by  cleaning  the  uterine  cavity  from  the  mucus 
which  covers  it,  either  by  injections  of  pure  water,  or  by  painting  it 


Fig.  199. — Canula  on  whicli  a  fine  india-rabber  sound  may  be  screwed,  and 
wbich  is  fixed  at  the  other  end  to  the  small  injection  syringe. 


Fig,  200. — Small  graduated  syringe  for  making  uterine  injections.  1,  syringe 
in  its  metal  case,  the  canula  enclosed  in  the  stem  of  the  piston  ;  2,  syringe 
ready  for  use,  which  may  be  fitted  to  the  metal  sound  or  to  a  gum-elastic 
sound  by  means  of  the  canula. 

with  yolk  of  egg  to  form  an  emulsion  with  the  mucus  and  thus  to 
expel  it  more  easily.  Then  a  caustic  injection  is  made.  The  use  of 
the  uterine  sound  greatly  facilitates  the  operation.  Whether  we  use 
a  fine  india-rubber  sound  introduced  by  means  of  a  wire  in  the  interior, 
which  is  withdrawn  immediately  afterwards,  or  a  hollow  uterine  sound 
made  after  the  model  of  Simpson's,  it  is  in  any  case  useless  to  have 
one  with  a  double  canula,  as  the  liquid  should  be  able  to  flow  back 
round  about  the  sound,  which  ought  to  move  freely  in  the  orifice.  As 
for  the  instrument  of  propulsion,  whether  the  india-rubber  bag  of 
Hardy  (of  Dublin)  be  used,  or  the  graduated  syringe  which  Collin 
has  made  at  my  request,  the  process  is  the  same,  and  consists  in  first 
introducing  the  sound,  then  adjusting  the  syringe  to  its  extremity  and 
'  Essais  sur  le  traitement  methodique  cles  maladies  uterines.     Paris,  1840. 


220  TEEATMENT    OF  UTEEINE    DISEASES    IN    GENERAL 

propelling  the  liquid  very  slowly,  so  as  not  to  distend  the  cavity  of  the 
uterus,  lest  the  sound  by  filling  the  orifice  should  prevent  the  free 
return  of  the  liquid  into  the  speculum.  The  speculum  is  always  indis- 
pensable when  a  caustic  liquid  is  used,  to  prevent  the  cauterisation  of 
the  vagina  by  the  liquid  as  it  issues  from  the  uterus. 

Nothing  could  be  simpler  or  more  efficacious  than  these  injections 
if  the  susceptibility  of  the  mucous  membrane,  the  narrowness  of  the 
cervico- uterine  canal,  and  the  permeability  of  the  Fallopian  tubes  were 
not  the  source  of  dangers,  all  the  greater  that  they  are  sometimes  not 
foreseen,  and  that  the  greatest  skill  and  prudence  have  not  always  suc- 
ceeded in  preventing  them.^  As  for  myself,  I  have  often  made  these 
injections  without  any  bad  result;  but  although  I  have  never  had 
occasion  to  deplore  the  death  of  a  patient,  I  have  sometimes  seen  the 
instantaneous  occurrence  of  such  formidable  accidents  after  injections, 
that  I  have  resolved  never  to  make  another  caustic  injection,  or  even 
one  of  simple  water,  unless  assured  of  a  free  passage  through  the  cervico- 
uterine  orifice,  allowing  of  the  easy  reflux  of  the  liquid  into  the  vagina 
as  soon  as  it.  has  filled  the  uterine  cavity.  In  this  case  there  is  nothing 
to  fear.  We  may,  therefore,  without  misgiving  follow  this  rule  : 
to  make  an  injection  into  the  uterus  when  the  orifice  is  sufficiently  wide 
to  allow  the  excess  of  liquid  to  flow  hack  through  the  cervix ;  in  all 
other  cases  to  abstain  from  this  mode  of  treatment.^  This  operation, 
moreover,  must  only  be  performed  in  the  middle  of  the  intermenstrual 
period. 

The  liquids  used  are :  simple  water,  solutions  of  tannin,  alum,  sul- 
phate of  zinc,  nitrate  of  silver,  acid  nitrate  of  mercury,  tincture  of 
iodine,  perchloride  of  iron,  and  even  of  chloride  of  zinc. 

1  must,  however,  repeat  that  every  liquid  caustic  may  become 
dangerous  :  (1)  because  it  touches  all  parts  of  the  mucous  membrane, 
and  so  may  cause  too  extensive  a  destruction,  or  excite  an  irritation  in 
the  mucous  membrane,  followed  by  inflammation  dangerous  in  itself, 
and  which  may  spread  to  the  mucous  membrane  of  the  Fallopian  tubes 
and  to  the  peritoneum ;  {;Z)  because  the  uterine  cavity  is  so  small  that 
all  the  liquid  may  not  flow  back  by  the  orifice,  and,  even  when  it  can 
return  freely,  part  of  it  may  penetrate  the  orifice  of  the  Fallopian 
tube  and  cause  fatal  inflammation.  Therefore  I  restrict  intra-uterine 
injections,  in  those  rare  cases  which  absolutely  require  them,  to  simple 
water  used  as  a  lotion,  or  to  a  very  small  quantity  of  catheretic  rather 
than  caustic  liquid : — tincture  of  iodine,  perchloride  of  iron,  nitrate  of 
silver,  beginning  with  a  very  weak  solution  and  increasing  very  gra- 
dually ;  and  I  never  make  thetn  when  there  is  any  cause  to  fear  that, 
owing  to  a  flexion,  a  deviation  of  the  cervico-uterine  canal,  a  constric- 
tion of  the  orifice,  or  any  other  obstacle,  the  liquid  injected  cannot 
return  easily  from  the  uterine  cavity  into  the  vagina.     This  is  no  doubt 

^  Nseggerath  has  related  a  case  of  death  resulting  from  caustic  injections 
into  the  uterus  {Neio  YorTc  Journal  of  Medicine  and  Gazette  med  de  Paris, 
1861,  p.  190). 

2  Gantillon,  du  Catarrhe  uterin.  These  de  Paris,  1868.  Guyot,  des  Injec- 
tions intra-uterines.     These  de  Paris,  1868. 


METHODS  OF  TREATMENT  AND  MEDICATIONS 


221 


equivalent  to  a  half  condemnation.  In  fact,  I  hardly  ever  perform 
this  little  operation  since  I  recognised  its  attendant  dangers,  and  espe- 
cially since  I  ascertained  the  entire  freedom 
from  injurious  results  of  the  introduction 
into  the  cavity  of  the  uterus  of  a  small 
quantity  of  solid  or  pulverised  nitrate  of 
silver.  There  are,  however,  cases  of  obsti- 
nate haemorrhage  and  abundant  leucorrhoea, 
where  injections  of  tannin,  iodine,  &c.,  have 
been  of  great  use. 

Intra-uterine  cauterisation  ought  only  to 
be  practised  with  nitrate  of  silver.  Any 
other  caustic  seems  to  me  dangerous,  except 
in  cases  of  serious  alteration  with  suspicious 
vegetation  of  the  whole  mucous  surface, 
when  nitric  or  chromic  acid,  in  solutions  of 
varying  strength,  or  even  chloride  of  zinc 
may  be  indicated. 

Nitrate  of  silver  may  be  applied  to  the 
uterine  cavity  in  various  ways.  It  may  be 
introduced  by  a  brush  dipped  in  a  concen- 
trated solution  of  the  caustic,  or  the  wet 
brush  may  be  rolled  in  powdered  nitrate  of 
silver,  or  a  sponge  tent  may  be  covered 
with  wax  and  rolled  in  the  powder,  according 
to  Gillespie^s  plan  {Lyon  medical,  20 
aout,  1871).  We  may  even  with  the 
brush,  which  presents  none  of  the  dangers 
of  injections,  apply  other  caustics,  such  as 
the  aqueous  solution  of  tincture  of  iodine, 
perchloride  of  iron,  and  even  chloride  of 
zinc,  as  I  have  done  several  times. 

The  mode  I  adopt  is  as  follows  :  I  com- 
mence by  introducing  the  sound  into  the 
cavity  so  as  to  learn  the  direction  to  be 
given  to  the  instrument,  taking  care  always 
not  to  cause  hsemorrhage.  Immediately 
after  withdrawing  it  I  insert  a  fine  camePs- 
hair  brush,  mounted  on  a  long  handle  and 
soaked  in  a  strong  solution  of  nitrate  of 
silver,  or  rolled  in  the  powder,  and  repeat 
the  application  a  second  and  even  a  third 
time  if  the  os  internum  remains  sufficiently 
open  to  allow  of  it.  Whilst  this  is  being  done 
I  fix  the  cervix  by  means  of  the  converging 
tenaculum  hook  forceps.  In  most  cases  this 
application  repeated  once  a  month  three  or 
four  times  is  quite  sufficient  to  produce  the 
desired  effect ;  but  in  some  rare  cases,  where  a  more  powerful  action  is 


Fig.  201. — Cauterisation  of 
the  uterine  cavity  by 
lueans  of  a  brush. 


222 


TEEATMENT    OF    UTERINE    DISEASES    IN    GENERAL 


necessary,  it  has  been  suggested  that  the  crayon  should  be  introduced 
and  applied  to  the  mucous  membrane  lining  the  cavity  in  the  same 
way  as  to  ulcers  of  the  cervix,  or  to  the  proud  flesh  of  an  external 
wound.  Till  lately,  however,  practitioners  feared  the  danger  that 
might  be  incurred  by  a  fragment  of  the  caustic  being  broken  off  and 
remaining  in  the  womb.  Having  assured  myself  not  only  of  the 
harmlessness,  but  even  of  the  good  results  consequent  on  this  accident, 
and  having  considered  the  advantages  which  might  accrue  from  leav- 
ing a  fragment  of  nitrate  in  the  cavity  of  the  womb  provided  its  use 
was  indicated,  and  that  precautions  were  taken  to  avoid  troublesome 
consequences,  I  have  not  hesitated  to  try  this  means  of  cure  for  obsti- 
nate leucorrhoea  and  fungous  growths.  Experience  has  answered  my 
expectations  in  the  most  satisfactory  way,  and  at  present  the  introduc- 


FiG.  202. — Uterine  caiis- 
tic-holdei'.  a,  sound  ; 
b,  stylet. 


Fig.  203. — Extremity  of  different  uterine  caustic- 
holders.  1,  large  sound  with  two  large  orifices 
for  ointment ;  2,  3,  smaller  sounds  for  passing 
solid  or  pulverulent  caustics  into  the  uterus. 


tion  of  nitrate  of  silver  into  the  uterus  is  not  only  one  of  the  little 
operations  which  I  perform  as  frequently  as  cauterisation  of  the  cervix 
or  of  the  cervical  cavity,  but  it  is  a  recognised  application  in  gyneco- 
logical therapeutics.  I  perform  it  in  the  following  way  :  I  choose  a 
crayon  of  varying  length,  according  to  the  size  of  fragment  I  intend  to 
leave  in  the  uterus ;  generally  a  very  small  crayon  is  sufficient.     I 


METHODS    OP    TEEATMENT   AND   MEDICATIONS  223 

round  and  point  the  extremity,  rolling  it  between  the  fingers  in  a 
piece  of  coarse  wet  linen,  so  as  to  facilitate  its  introduction  ;  then  I  fix 
it  in  an  ordinary  platinum  caustic-holder  with  a  long  handle,  or  seize 
it  with  the  uterine  forceps,  or  place  it  in  the  end  of  Braun's  sound. 
After  having  introduced  the  sound  in  order  to  learn  the  direction  of 
the  cervico-uterine  canal,  but  very  gently  so  as  to  avoid  causing  spas- 
modic contractions  of  the  orifice,  I  apply  the  crayon  to  the  uterine 
cavity ;  then,  in  place  of  trying  to  withdraw  it  intact,  I  try  to  push  it 
in  by  partly  opening  the  forceps,  or  to  break  it  by  inclining  the 
caustic-holder  abruptly,  or  I  thrust  it  in  by  means  of  the  gutta-percha 
sound  invented  by  Braun  of  Vienna^  for  this  purpose;  immediately 
afterwards  I  introduce  into  the  vagina  a  large  tampon,  soaked  in  salt 
water,  so  as  to  neutralise  the  nitrate  of  silver  which,  as  it  dissolves, 
issues  from  the  uterine  cavity,  and  to  protect  the  vagina  and  cervix.  I 
keep  this  plug  in  place  by  a  larger  dry  one,  and  then  withdraw  the 
speculum.  In  addition  to  these  the  same  precautions  are  taken  to 
prevent  the  development  of  inflammation  as  are  used  after  the  actual 
cautery. 

I  may  say  that  I  do  not  know  a  more  heroic  means  of  treatment 
than  leaving  a  fragment  of  crayon  in  the  uterine  cavity  in  those  cases 
of  large  fungous  granulations  fo r  which  Eecamier  invented  his  curette, 
and  above  all  in  cases  of  chronic  and  obstinate  leucorrhoea,  which 
cause  despair  to  patients  and  physicians  alike.  It  seldom  happens 
that  this  little  operation  is  required  a  second  time. 

I  have  never  seen  serious  accidents  follow  this  mode  of  treatment. 
The  cauterisation  of  the  vagina  is  prevented  by  the  introduction  of  the 
plug  soaked  in  salt  water;  inflammation  of  the  uterus  or  of  its  mucous 
membrane  by  baths,  vaginal  irrigations  and  absolute  rest;  and  pain, 
spasm  or  nervous  erethism,  which  are  the  most  common  accidents,  by 
an  antispasmodic  draught  or  an  opiate  enema. 

I  have  only  once  seen  excruciating  pain  alleviated  neither  by  baths, 
antispasmodics,  nor  narcotics.  It  was  owing  to  expulsive  efforts  and 
uterine  contractions  produced  by  a  considerable  swelling  of  the  cervix 
which  caused  a  temporary  occlusion  of  its  orifice.  .  This  morbid  condi- 
tion, which  prevented  the  expulsion  of  the  mucus  abundantly  secreted 
under  the  irritating  influence  of  the  nitrate  of  silver,  being  the  sole 
cause  of  these  pains,  a  cause  purely  mechanical,  I  incised  the  cervix  a 
few  hours  after  the  operation  to  facilitate  the  expulsion  of  the  mucus, 
as  well  as  of  the  nitrate  of  silver  itself.  The  symptoms  ceased  imme- 
diately, and  the  good  eflects  of  the  cauterisation  were  produced  all  the 
same.  In  all  my  other  cases,  the  pain,  which  has  occurred  more 
frequently  than  after  cauterisation  of  the  cervix,  and  which  has  some- 
times been  severe,  has  always  yielded  to  general  and  local  antispas- 
modics, and  to  baths  asiociated  with  continuous  vaginal  irrigation. 

Besides,  if  the  nitrate  is  only  left  in  the  uterine  cavity  when  the 

'  Since  then  a  year  never  passes  without  a  new  instrument  heing  invented 
for  precipitating  a  fragment  of  nitrate  of  silver  into  the  uterus,  which  is  the 
best  refutation  of  the  objections  made  to  my  method,  i.e.  before  having  tried 
it  experimentally. 


224  TREATMENT   OF    UTEEINE    DISEASES    IN    GENERAL 

orifices  are  gaping,  tlie  mucus,  which  is  abundantly  secreted  imme- 
diately after  the  operation,  is  easily  expelled  under  the  influence  of 
uterine  contractions,  and  it  rarely  happens  that  these  contractions  are 
painful.  Sometimes  the  orifices  are  so  patent  that  the  crayon  is 
expelled  with  the  mucus.  As  it  is  not  always  necessary  to  introduce 
a  large  fragment,  I  often  use  ordinary  open  sounds  furnished  with  a 
piston  for  propelling  a  small  bit  of  nitrate,  or  simply  the  powder  or  an 
ointment. 

The  contra-indications  to  this  little  operation  are  very  clear.  The 
first  and  most  absolute  is  the  existence  of  an  inflammatory  state  of  the 
uterine  system.  This  rule  alone  would  prevent  many  accidents. 
Another  important  contra-indication  is  never  to  leave  the  crayon  in  the 
uterine  cavity  when  the  secretions  would  have  any  difficulty  in  escaping. 
Consequently  I  never  do  so  in  cases  of  flexion,  deviation  of  the  uterine 
canalj  or  constriction  of  the  orifices. 

I  must  now  explain  what  takes  place  through  the  agency  of  this 
mode  of  cauterisation,  and  also  account  for  its  innocuity.  The  chief 
cause  of  its  harmlessness  is  that  the  mucous  membrane  of  the  womb 
does  not  experience  the  direct  and  immediate  action  of  the  caustic.  In 
fact  the  nitrate  of  silver  cannot  be  brought  into  immediate  contact  with 
the  mucous  membrane,  nor  can  it  produce  an  energetic  cauterisation  on 
any  part  of  it.  The  presence  of  the  crayon  causes  hypersecretion  of 
mucus,  which  protects  the  membrane,  the  crayon  being  enveloped  with 
the  mucus  which  coagulates  around  it  from  the  first;  afterwards  it  is 
only  through  this  envelope  that  an  exchange  can  be  effected  between 
the  caustic  and  the  secretions  of  the  uterine  cavity.  We  know  this 
from  seeing  the  crayon  as  it  escapes  seven  or  eight  days  afterwards,  or 
rather  its  form,  for  it  is  strangely  altered,  decomposed,  softened  and 
foliated.  It  is  evident  that  it  has  been  greatly  modified  by  its  sojourn 
in  the  uterine  cavity ;  it  is  evident  also  that  it  has  not  dissolved  as  it 
would  have  done  in  a  glass  of  water.  A  series  of  successive  exchanges 
have  been  made  between  the  elements  of  which  it  is  composed  and 
those  of  the  mucus  secreted  by  the  membrane  lining  the  uterus.  The 
impression,  therefore,  made  on  the  organ  by  the  caustic  must  have  been 
very  gradual.  This  action  difl'ers,  without  doubt,  from  cauterisation 
properly  so  called ;  we  can  understand  also  that,  if  some  parts  are  more 
aft'ected  than  others,  it  must  be  the  superficial  ones,  the  granulations, 
the  exuberant  fungosities,  the  hypertrophied  follicles.  In  short,  we 
can  understand  that  this  modification  of  the  uterine  cavity  is  prefer- 
able to  that  produced  by  injections  which  penetrate  further,  reaching 
all  the  recesses  of  the  mucous  membrane,  even  of  the  Fallopian  tubes, 
and  presenting  dangers  the  existence  of  which  is  proved  both  by 
experience  and  theory. 

4.  Eecamiev^s  uterine  curette  is  a  metallic  stem  in  steel,  twelve  inches 
in  length,  of  the  thickness  of  an  ordinary  goose  quill,  cyHndrical  in 
the  middle,  presenting  at  each  of  its  extremities  a  curve,  which  allows 
of  its  being  more  easily  adapted  to  the  axis  and  direction  of  the  uterus. 
Its  curves  are  disposed  inversely  with  regard  to  each  other.  Their 
concave  sides  are  excavated  in  deep  grooves  of  unequal  length,  the 


METHODS    OF   TREATMENT   AND    MEDICATIONS 


225 


edges  of  which,  although  blunt,  are  very  fine,  like  those  of  a  rasp, 
and  capable  of  removing  exuberances  of  the  mucous  membrane  by 
friction.     After  introducing  the   instrument  into  the  uterine  cavity 


Fig.  204. 


4y 

Fig.  205. 


pi 

i 


^4^ 


Fig.  206. 


Fig.  204. — Eecamier's  uterine  curette. 

Fig.  205. — Sims's  curette,  eifecting  abrasion  by  the  external  border.     I  have 

had  one  made  which  abrades  with  the  internal  border. 
Fig.  206. — Button-hook  curette,   diilering  from  the   other  two  in  not  being 

closed,  so  that  it  can  be   used  for  the  removal  of  a  polypoid  excrescence. 

The  stems  of  these  instruments  not  being  tempered,  they  can  be  inclined 

to  suit  the  direction  of  the  cervico-uterine  canal. 

Recamier  used  to  impart  to  it  light  movements  of  circumduction  as 
well  as  in  a  vertical  direction,  so  as  to  explore  successively  every  part 
of  the  mucous  membrane.  If  he  found  that  some  points  were 
especially  exuberant,  he  scraped  the  mucous  membrane  with  one 
edge  of  the  groove,  and  when  both  of  the  walls  seemed  sufficiently 
smooth  he  withdrew  the  instrument,  taking  care  to  turn  the  groove 
upwards,  so  as  to  bring  away  the  fungosities  just  abraded.  I  have 
often  in  this  manner  extracted  fungosities,  which  were  the  only  cause 

15 


226 


TEEATMENT    OF    UTERINE    DISEASES   IN    GENEEAL 


of  metrorrhagia  which  ceased  after  abrasion  by  the  curette.  Eecamier 
sometimes  repeated  the  operation  several  times  at  intervals  of  a  few 
days.  Each  scraping  was  followed  by  cauterisation  with  nitrate  of 
silver  and  bathing  of  the  uterine  cavity. 

This  operation  has  been  severely  criticised  by  some  and  too  much 
praised  by  others.  To  say  thatMarjolin,  Robert,  Trousseau,  Nelaton, 
Maissonneuve,  Nonat,  &c.,  have  practised  it  several  times  with  success 
is  a  sufficient  justification  of  the  use  of  the  curette.  When  there  are 
no  fungosities  it  cannot  do  very  great  harm  to  pass  the  curette 
lightly  over  the  mucous  membrane,  and  when  there  are  it  alone  can 
remove  them  quickly  and  surely.  It  is,  therefore,  undoubtedly  of 
great  value.  I  specially  recommend  its  use  for  the  abrasion  of  a  little 
polypus  or  fungosity  clearly  diagnosed  by  means  of  the  sound.  In 
such  a  case  it  may  be  necessary  to  have  recourse  to  Sims's  curette, 
which  is  broad,  or  to  mine,  which  I  have  left  open  on  one  side  in  the 
form  of  a  button  hook. 

It  cannot  be  denied  that  in  cases  of  softening  of  the  uterine  tissue 
the  curette  may  have  produced  perforations  which,   though  cured  in 
some  cases,  have  in  others  had  a  fatal  result.     The  danger  of  this 
accident,  which  is  very  rare  and  always  easy  to  avoid,   ought  always 
to  be  present  to  the  mind  of  the  surgeon,  who  will 
/\        use  every  precaution  and    even  abstain  from   abra- 
L^        sion  in   all    cases    where  flexion  'of   the   uterus  or 
I'*  J        softening  of  its  tissue  would  facilitate  the  penetra- 
tion of  the  curette  through  the  uterine  walls. 

5.  Simpson's  infra-uterine  dry  cupping  instrument 
is  a  hollow  sound  perforated  with  holes  at  the  terminal 
extremity,  whilst  the  other  end  is  screwed  on  to  a 
little  aspirating  pump,  by  means  of  which  a  vacuum 
can  be  made.  The  diameter  of  the  sound  is  suffi- 
cient to  fill  the  cervico-uterine  orifice  when  the 
rounded  extremity  is  in  the  cavity  of  the  womb. 
In  proportion  as  a  vacuum  is  made  in  the  body  of 
the  pump  a  kind  of  aspiration  is  exercised  on  the 
uterine  mucous  membrane  which  comes  in  contact 
with  the  little  openings  of  the  sound.  After  repeat- 
ing this  application  several  days  running,  at  the 
time  when  the  catamenia  ought  to  appear,  there  is 
a  flow  of  blood  towards  the  mucous  membrane,  and 
at  last  there  may  be  a  little  oozing  of  blood  from  it. 
Simpson  used  to  have  recourse  to  this  little  opera- 
tion for  amenorrhoea,  but  it  has  not  been  adopted  by 
the  profession.  It  is  a  complement  of  the  intro- 
duction of  the  galvanic  stem  and  of  the  dilatation  of 
the  orifice  by  stem  pessaries  of  gradually  increasing 
diameter. 
B.  Special  operations. — The  operations  which  remain  to  be  men- 
tioned are  so  entirely  special  that  the  description  of  them  cannot  well 
be  separated  from  the  history  of  the  diseases  for  which  they  are  indi- 


Fig.  207. 
Intra  -  uterine 
sonnd    for    drj- 
cupping  the  ute- 
rus (Simpson). 


METHODS    OF    TREATMENT    AND    MEDICATIONS 


227 


Fig.  208.— Simpson's  simple     Fig.  209.— Mathieu's      Fig.  210.— Division  of  the  os  ex- 
hysterotome.  double  liysterotome.         ternum  with  the  blunt-pointed 

1,  open ;  2,  shut.  concealed  bistoury  and  diver- 

gent tenaculum  hook  forceps. 

cated.  Some  of  tliem,  though  offering  no  apparent  difficulty,  and 
though  devoid  of  all  real  gravity,  are  not  on  that  account  unaccom])anicd 
by  dangers,  occurring  either  from  ignorance  of  the  exact  anatomical 
knowledge  required,  or  from  induced  hccmorrhage,  or  even  from  serious 


228  TREATMENT    OF    UTERINE    DISEASES    IN    GENERAL 

accidents  consequent  upon  them,  such  as  the  putrefaction  of  pus,  the 
entrance  of  air  into  a  purulent  or  sanguineous  centre,  the  decomposi- 
tion of  liquids  contained  therein  and  the  purulent  or  y)utrid  absorp- 
tion which  may  be  one  of  these  consequences.  Others  take  their 
place  among  the  most  serious  operations  of  surgical  art,  and  neces- 
sitate special  knowledge  as  well  as  an  experienced  hand  and  a  mind 
familiar  with  all  the  accidents  and  all  the  resources  of  general 
surgery. 

6.  Amongst  the  first  class  we  may  include  division  of  the  cervical 
orifices  ;  perforation  of  the  hymen,  vagina  or  uterus,  in  cases  of  atresia 
of  these  organs  ;  puncture  of  peri-uterine,  uterine,  or  ovarian  tumours, 
whether  by  the  vagina  or  the  abdomen ;  injections  of  various  kinds  into 
centres,  the  contents  of  which  have  previously  been  evacuated. 

The  division  of  the  cervical  orifices  indicated  in  cases  of  constric- 
tion, of  mechanical  and  even  of  membranous  dysmenorrhoea,  sterility, 
or  even  of  intra-uterine  tumour  (to  facilitate  means  of  access),  is 
performed  by  means  of  simple  instruments  such  as  scissors,  bistouries, 
sharp-  or  probe-pointed,  with  a  director,  &c.,  as  on  any  other  part  of 
the  body,  with  this  difference  that  these  instruments  must  be  long 
enough  to  reach  the  uterus.  Sometimes  it  is  more  convenient  to 
use  special  instruments  or  hysterotomes,  the  concealed  blades  of  which 
are  made  to  spring  out  from  their  sheath  wh^n  required.  They  may 
be  either  single  or  double-bladed  like  lithotomy  knives,  which  they 
resemble  in  this  respect.  The  simple  hysterotome  invented  by  Simpson 
is  one  of  the  most  useful.  Those  which  are  double-bladed  are 
preferable  in  some  circumstances,  owing  to  the  rapidity  with  which 
they  allow  of  the  operation  being  performed.  Or  short-bladed 
straight  scissors  may  be  used.  Kiichenmeister  has  invented  a  pair, 
the  external  blade  of  which  is  furnished  with  a  point  which  fixes 
it  firmly  in  the  uterine  tissue;  others  have  blades  with  teeth  like 
a  saw  to  prevent  hsemorrhage.  As  for  myself,  I  prefer  fixing 
the  cervix  by  means  of  diverging  tenaculum  hook  forceps  introduced 
into  its  cavity  and  stretching  the  os  so  as  to  facilitate  its  incision  to 
the  required  depth  by  a  simple  bistoury  v^'ith  a  fine  concealed  blade, 
like  that  of  Blandin.  Sometimes  simple  division  is  not  enough,  it 
being  impossible  to  preserve  a  sufficiently  large  opening  without  really 
performing  autoplasty  of  the  orifice.  There  is  a  great  difference  between 
division  of  the  os  externum  and  the  os  internum  as  regards  the 
gravity  of  the  operation.  Iq  performing  the  last  great  care  must  be 
taken  not  to  pass  beyond  the  uterine  tissue.  My  reason  for  preferring 
the  simple  tenotomy  knife  or  Simpson^s  hysterotome  to  the  double- 
bladed  one  is  that  I  generally  make  a  superficial  incision,  dilating 
afterwards  with  sponge  tents.  It  should  always  be  remembered  that 
this  operation  must  never  be  performed  at  the  menstrual  period,  or 
even  within  a  week  of  the  time. 

I  shall  simply  refer,  as  a  means  of  treatment,  to  dilatation  of  the 
cervix  by  bougies,  stem  pessaries,  sponge  tents,  or  other  dilating 
bodies,  about  which  I  have  already  spoken  in  detail  as  means  of 
diagnosis. 


METHODS   OF    TREATMENT    AND    MEDICATIONS  229 

Punctures  are  generally  made  with  trocars  of  various  forms,  straight 
or  bentj  and  of  different  sizes,  from  the  exploratory  trocar  intended  for 
capillary  punctures  in  supposed  abscesses  of  the  Fallopian  tube  or 
peri-uterine  abscesses  to  the  large  one  with  which  an  ovarian  cyst  is 
punctured,  especially  in  ovariotomy,  in  order  to  hasten  and  facilitate 
the  escape  of  the  thick  fluid  often  contained  in  it.  These  different 
kinds  of  trocars,  as  well  as  the  apparatus  annexed  to  them  either  for 
increasing  the  orifice  in  cases  of  hematocele  or  retro-uterine  abscess  or 
for  retaining  the  walls  of  the  cyst  and  preventing  effusion  of  the  fluid 
into  the  peritoneum  during  ovariotomy,  will  be  described  with  each  of 
these  diseases  and  the  operations  which  they  necessitate. 

Deep  injections,  generally  more  injurious  than  useful  unless  simply 
detersive,  are  made  into  the  various  peri-uterine  centres  or  into  ovarian 
cysts,  as  into  every  other  enclosed  cavity,  by  means  of  a  syringe 
fitted  on  to  the  canula  of  a  trocar.  I  have  sometimes  been  able  with 
great  advantage  to  substitute  for  these  injections  real  lotions  made 
with  a  double  canula  sound  to  which  a  small  hydroclyse  has  been 
fixed. 

7.  The  second  class  of  these  special  operations  comprises  antoplasty 
and  the  more  or  less  serious  operations  necessitated  by  the  partial  or 
total  absence  of  the  vulvo-uterine  canal,  the  excision  or  amputation  of 
the  cervix,  the  ablation  of  polypi  by  ligature  or  bistoury,  the  reduction 
of  displacements,  the  taxis  for  the  reduction  of  uterine  inversion,  the 
extirpation  of  pediculated  or  interstitial  fibromata,  and,  lastly,  amputa- 
tion of  the  ovary  and  of  the  uterus — an  operation  revived  in  our  times 
with  great  success. 

The  operations  necessitated  by  extensive  vaginal  imperforations  or 
obliterations  are  very  serious,  their  success  being  very  variable  and 
depending  on  the  conditions  under  which  they  are  performed.  Their 
great  difficulty  arises  from  the  necessity  of  performing  autoplasty  of  a 
canal  without  having  a  sufficient  extent  of  mucous  membrane.  Hence 
the  danger  of  encroaching  on  neighbouring  organs  (bladder  or  rectum) 
whilst  making  a  way  by  incision,  dilatation,  tearing,  &c.,  in  the  narrow 
space  which  separates  them.  Hence  also  the  imperfection  of  the 
results  obtained,' owing  to  the  impossibility  of  lining  the  new  canal 
with  true  mucous  membrane,  at  least  to  the  extent  required,  whilst 
almost  all  the  benefit  of  the  operation  is  lost  owing  to  the  formation 
of  retractile  cicatricial  tissue. 

Amputation  of  the  cervix,  indicated  in  cases  of  conicity,  elongated 
hypertrophy,  or  incurable  organic  alteration  of  this  segment  of  the 
uterus,  is  performed  by  means  of  long  curved  bistouries  or  scissors 
while  the  organ  is  pulled  down  ;  in  cases  of  hypertrophy  of  the  supra- 
vaginal portion  a  long  and  troublesome  dissection  is  required,  necessi- 
tating great  precautions  against  hcemorrhage.  Consequently  it  is 
better,  as  a  rule,  to  perform  the  operation  with  the  thermo-cautery. 

The  same  remarks  are  applicable  to  the  removal  of  polypi.  To  the 
methods  already  mentioned  we  may  add  avulsion  and  torsion  for  small 
vascular  tumours,  and  the  ligature,  especially  the  elastic  ligature,  used 
as  in  former  times  to  effect  strangulation  and  slow  detachment  by 


230  TREATMENT    OF    UTERINE    DISEASES    IN    GENERAL 

sloughing.  Later  on  we  shall  consider  the  respective  indications  for 
these  different  methods. 

The  reduction  of  chronic  uterine  inversion  and  the  extirpation  of 
the  tumour  are  operations  of  the  most  serious  description,  but  fortu- 
nately are  very  seldom  necessary. 

The  extirpation  of  fibromata,  although  easy  when  the  tumours  are 
small,  presents  great  difficulties  in  the  contrary  case,  and  has  led  to 
the  invention  of  a  most  ingenious  method  of  operation,  consisting  in 
the  division  of  the  tumour  in  situ,  and  the  extraction  of  it  in  fragments. 
These  extractions  necessitate  long  forceps  furnished  with  claws  and 
instruments  of  prehension  of  various  kinds,  in  the  fabrication  of  which 
great  perfection  has  been  attained  during  the  last  few  years.  The 
increase  in  size  of  fibrous  myomata  may  be  an  indication  for  the  partial 
or  total  extirpation  of  the  uterus  by  abdominal  section. 

Lastly  comes  ovariotomy,  the  most  serious  of  all  these  operations, 
so  serious  that  it  has  not  yet  been  generally  adopted.  The  minute 
details  necessary  and  the  various  rules  laid  down  by  the  enterprising 
minds  who  have  most  frequently  performed  this  conquest  of  modern 
surgery  must  be  reserved  till  we  come  to  the  description  of  ovarian 
cysts  and  serious  alterations  of  the  uterus. 


Gynecological  Apparatus 

My  pupils  have  very  frequently  asked  me  to  furnish  a  list  of  the  in- 
struments most  necessary  for  examining  women  affected  with  uterine 
diseases,  for  making  the  applications  and  performing  the  various 
operations  which  these  diseases  may  necessitate.  Now  the  instruments 
which  serve  in  diagnosing  diseases  of  women  have  the  exceptional 
advantage  pointed  out  by  Barnes,  viz.  that  of  serving  for  treatment  as 
well  as  for  diagnosis.  I  divide  gynecological  instruments  into  three 
categories :  1.  Those  which  the  gynecologist  ought  always  to  have 
with  him,  i.e.  those  that  are  necessary  for  examination,  for  applica- 
tions, and  even  for  unforeseen  and  extemporaneous  performance  of 
small  operations.  2.  Those  which  are  often  employed,  but  the  use 
for  which  is  neither  unforeseen  nor  indispensable.  3.  Lastly,  those 
intended  for  performing  more  important  operations,  whether  on  the 
genital  organs  or  on  other  parts  of  the  body. 

The  first  class  alone  constitutes  the  gynecologist's  apparatus.  The 
second  forms  what  I  may  call  the  special  arsenal  of  the  gynecologist. 
The  third  is  what  the  gynecologist  borrows  from  general  surgery. 

1. — The  Gynecologist's  Apparatus 

1.  Two  sizes  of  Sims's  speculum  as  modified  by  Courty,  i.  e.  two 
blades  with  handles  made  to  screw  off  and  on.  They  have  this  great 
advantage,  that  they  suffice  for  any  ordinary  diagnosis  or  application, 
whilst  any  other  may  possibly  be  useless  owing  to  the  narrowness 
of  the  vagina,  the  abnormal  direction  of  the  cervix,  the  presence  of  a 
tumour,  &c. 


GYNECOLOGICAL    IXSTRTTMENTS  231 

2.  One  or  two  pairs  of  Courly^s  dressing  forceps  (one  pair  straight, 
one  curved)  with  short  blades  and  blunt  points,  equally  suitable  for 
making  applications,  seizing  the  pedicle  of  a  tumour,  holding  a  needle, 
a  piece  of  sponge,  &c. 

S.  A  female  catheter,  and  by  preference  a  sigmoid  catheter. 

4.  A  uterine  sound  made  to  slide  into  its  handle. 

5.  Two  silver  sounds  perforated  at  the  point,  the  other  end  being 
made  to  fit  into  a  syringe'. 

6.  Two  fine  india-rubber  sounds  of  small  calibre,  also  made  to  fit 
on  to  the  syringe  by  means  of  a  conical  cauula  with  a  screw. 

7.  Blandin^s  long-bladed  concealed  bistoury. 

8.  Three  pairs  of  long  scissors  with  short  pointed  blades ;  one  pair 
straight,  another  curved,  the  third  elbowed. 

9.  Convergent  and  sliding  tenaculum  hook  forceps. 

10.  Divergent  tenaculum  hook  forceps  with  catch. 

11.  Two  fine  camePs  hair  brushes  on  long  handles. 

12.  Two  long  canulas  with  movable  piston,  one  an  intra-uterine 
solid  caustic  holder,  the  other  an  ointment  holder  like  those  of  Braun 
and  Barnes. 

13.  Two  of  Piecamier's  curettes,  one  narrow,  one  broad. 

14.  A  small  syringe  for  intra-uterine  injections  fitting  on  to  the 
sounds. 

15.  A  larger  syringe  for  washing  the  cavity  of  the  uterus  before 
and  after  cauterisation. 

To  this  list  of  instruments  1  will  add  a  short  one  of  medicaments 
which  the  gynecologist  wall  find  it  useful  to  have  beside  him ; — cold 
cream,  glycerine,  laudanum,  tincture  of  iodine^  perchloride  of  iron,  a 
nitrate  of  silver  point  in  a  glass  tube,  powdered  nitrate  of  silver  in  a 
glass  stoppered  bottle,  chloride  of  zinc  in  crystals  in  a  similar  bottle, 
canquoiu  plaster,  Priar  Come''s  red  arsenical  powder.  I  need  not  say 
that  I  have  only  mentioned  the  most  necessary,  passing  over  a  very 
large  number  of  most  useful  drugs,  such  as  chlorate  of  potash,  alum, 
tannin,  &c. 

2. — The  Gynecologist's  Special  Arsenal 

1.  Collin's  reflecting  lamp  wath  refracting  glass. 

2.  The  two  large  blades  of  my  speculum. 

8.  Two  of  the  same  in  wood,  to  be  used  when  the  potential  or  actual 
cautery  is  applied. 

4.  Cusco's  folding  bivalve  speculum. 

5.  Three  sizes  of  Ferguson's  glass  speculum. 

6.  Eolipyle  spirit  lamp  with  stand  for  cauteries. 

7.  Four  cauteries  for  ignipuncture,  the  points  and  bulbs  of  varying 
sizes. 

8.  Three  spear-shaped  cauteries,  one  straight,  the  others  more  or 
less  curved  ;    and  one  very  narrow  in  the  form  of'a  kniff 

9.  Six  prepared  sponge  tents  of  different  sizes. 

10.  Four  Courty's  galvanic  stem  pessaries,  different  sizes. 

11.  Sims's  bistoury  with  reversible  blade. 


232         TEEATMENT  OF    UTEEINE    DISEASES    IN    GENERAL. 

13.  Three  of  Startin's  hollow  needles,  one  straight,  one  curved  in 
the  axis,  and  a  third  (Courty's)  curved  perpendicularly  to  the  axis  like 
that  of  Deschamps,  all  furnished  with  Mathieu's  threader. 

13.  Long  but  fine  forceps  with  short  claws  and  catch,  straight  and 
elbowed. 

14.  Two  long  fine  tenaculum  hooks  with  handles,  one  single  the 
other  double, 

15.  A  long  blunt  hook.. 

16.  Two  curettes,  cutting  the  one  on  the  convex  (Sims's),  the  other 
on  the  concave  side  (Courty's). 

17.  A  curette  in  the  form  of  a  button-hook  (Courty). 

18.  A  long  and  fine  serre-noeud  for  extemporaneous  ligature,  and 
one  very  small  for  vascular  tumours  of  the  urethra. 

19.  Gooch's  canula  as  modified  by  Courty. 

20.  Naudinat's  large  size  hydroclyse,  with  straight  tubes  varying  in 
length  and  thickness. 

31.  A  supply  of  iron  wire,  silver  wire,  waxed  thread,  fine  whipcord, 
india-rubber  thread,  fine  india-rubber  tubing,  cotton  wool,  &c. 

3. — Instruments  common  to  the  Gynecologist  and  the 
General    Surgeon. 

I.  A  set  of  bistouries  with  long  handles  and  short  blades,  pointed 
or  blunt,  straight,  curved  on  the  flat,  or  elbowed  at  the  level  of  the 
blade. 

3.  MacClintocFs  corkscrew  or  vice  for  removing  polypi;  Aveling's 
polyptribe ;  Simpson's  polypotome. 

3.  Very  strong  single  or  double  tenaculum  hooks  open  or  concealed, 

4.  Chassaignac's  radiating,  convergent,  or  divergent  tenaculum 
hooks.     Courty's  semi-tenaculum  hooks  of  the  same  make. 

5.  Strong  polypus  forceps,  straight  or  curved,  with  lock. 

6.  Museux's  strong  tenaculum  hook  forceps,  some  very  concave,  for 
seizing  strong  tumours  (Robert's  pattern),  others  sliding  (Green- 
halgh's),  others  concealed,  and  springing  out  when  required  (Collin, 
Mathieu,  &c.). 

7.  Box  of  instruments  for  vesico- vaginal  and  recto- vaginal  fistulse. 

8.  Ovariotomy  box. 

9.  Straight  and  curved  ecraseur,  furnished  with  Emmet's  adjuster 
or  Aubry's  metallic  thread  for  holding  the  chain. 

10.  Paquelin's  thermo- cautery,  with  Courty's  ignipunctor  and 
curved  knife. 

II.  Galvano-cautery,  with  wire  and  electric  battery. 


CHAPTER  III 

GENERAL  CHARACTERISTICS  OF  UTERINE  DISEASES — THEIR  FREQUENCY 
PREDISPOSING  CAUSES — GENERAL  AND  LOCAL  SYMPTOMS — COM- 
PLICATIONS— PROGNOSIS — CLASSIFICATION. 

Hitherto  I  have  only  considered  the  characteristics  of  uterine  dis- 
eases with  regard  to  diagnosis  and  therapeutic  indications.  Now  I 
shall  endeavour,  by  considering  them  in  groups,  as  they  sometimes 
occur  naturally,  to  give,  not  perhaps  a  more  exact,  but  a  more  com- 
plete view  of  them,  showing  their  special  characteristics,  and  consider- 
ing the  degree  and  elements  of  their  curability  ;  in  short,  pointing  out 
the  various  forms  they  may  assume,  the  natural  divisions  into  which 
they  may  be  classified,  and  the  relative  frequency  and  importance 
occupied  by  each  of  them. 

1.  The  first  characteristic  of  uterine  diseases  is  their  frequency.  I 
have  already  refuted  the  opinion  of  those  who  assert  that  they  were 
less  frequent  formerly  than  now.  I  have  shown  how  it  was  that  they 
escaped  the  notice  of  the  ancients.  Is  it  necessary  to  explain  why  we, 
with  our  means  of  exploration,  encounter  them  so  often?  Could  it  be 
otherwise  with  an  organ  which  everything  seems  to  have  conspired  to 
make  the  point  towards  which  all  morbid  phenomena  naturally  tend 
and  the  starting-point  of  almost  all  constitutional  disorders.  Its 
position  exposes  the  uterus  to  constant  pressure  from  the  weight 
of  the  abdominal  viscera,  whilst  the  accomplishment  of  its  functions 
necessitates  not  only  a  hypersemia  like  that  produced  in  other  organs 
but  considerable  and  repeated  sanguineous  fluxions,  serious  nervous 
disturbance,  complete  change  of  tissue  and  more  or  less  serious  trau- 
matism, in  a  word,  the  natural  phenomena  of  menstruation,  coitus, 
pregnancy,  delivery ;  in  short,  the  uterus  reacts  constantly  on  all  the 
organism,  and  all  the  organism  reacts  on  it :  2^'^'opter  solum  uterum^ 
mulier  id  est  quod  est.  Now  that  we  know  the  physiological  import- 
ance of  the  ovaries  and  how  closely  they  are  connected  with  the 
uterus  we  can  apply  the  same  adage  to  them,  admitting  an  equal 
frequency  in  the  occurrence  of  ovarian  disease. 

This  frequency  is  so  great  that  it  often  allows  of  our  presuming  the 
existence  of  uterine  disease,  which  at  the  time  may  be  only  latent. 
When  the  cause  of  more  or  less  serious  general  symptoms  cannot  be 
discovered,  attention  should  be  drawn  to  the  genital  economy  and  inves- 
tigations should  accordingly  be  made  in  that  direction.  By  inquiring 
into  the  circumstances  which  have  a  more  or  less  considerable  share  in 
the  production  of  uterine  diseases,  we  shall  at  the  same  time  account 
for  their  frequency  and  recognise  the  character  assumed  by  them  in 
their  development. 


234  UTEEINE  DISEASES 

2.  Many  predisposing  cmises  are  known  but  very  few  determming 
causes.  Uterine  diseases  are  generally  awakened  by  the  slow  and 
gradual  changes  produced  in  the  vitality  and  structure  of  the  organ 
under  the  latent  and  continuous  influence  of  a  diathesis ;  but  we 
cannot  always  determine  tlie  causes  which  bave  originated  them. 
After  allj  these  are  of  no  importance  as  far  as  treatment  is  concerned  j 
whether  they  are  due  to  a  traumatism,  to  the  effects  of  delivery  or 
abortion,  or  to  a  reaction  from  some  injurious  impression^  these  are 
often  only  the  accidental  causes  which  may  have  put  the  match  to  the 
fire,  but  they  have  neither  prepared  it  nor  kept  it  up.  Therefore,  for 
all  practical  purposes,  it  is  sufficient  to  consider  the  predisposing 
causes  of  these  diseases,  local  as  well  as  general. 

The  predisposing  local  causes,  which  depend  on  anatomical  and 
physiological  conditions  peculiar  to  the  uterus,  explain  not  only  the 
frequency  of  the  diseases  of  this  organ,  but  the  relatively  greater 
frequency  of  some  of  them,  the  favorite  seat  of  others,  &c.  Thus  the 
dependent  situation  of  the  uterus  accounts  for  the  frequency  with 
which  it  is  congested  and  engorged,  as  well  as  for  the  difficulty 
experienced  in  elfecting  a  cure.  The  multiplicity  of  its  means  of  sus- 
pension and  the  change  which  they  undergo  in  the  accomplishment  of 
functions  (pregnancy,  delivery,  &c.)  are  the  natural  causes  of  various 
displacements  of  the  uterus  and  often  of  its  engorgement.  Its  con- 
nections with  the  bladder,  the  rectum  and  the  pelvis  with  the  cellular 
tissue  which  fills  it  and  the  peritoneal  folds  lining  it,  explain  the 
influence  which  may  be  exercised  by  these  neighbouring  organs  on  the 
uterus,  and  vice  versa. 

The  various  phases  of  development  dispose  the  uterus  to  disease  in 
one  part  more  than  another.  The  precocious  development  of  the 
cervix  renders  the  cervical  cavity  liable  to  catarrh  even  before  puberty. 
The  later  preponderance  of  the  body  explains  the  frequency  of  disease 
of  this  organ  in  the  adult.  Arrested  development  may  suffice  to 
cause  a  decided  flexion,  especially  anteflexion,  which  is  only  the  per- 
sistency of  the  fcetal  condition. 

Even  its  structure  involves  a  tendency  in  the  organ  to  certain  morbid 
conditions.  The  predominance  of  fibro-muscular  tissue  disposes  the 
uterus  to  general  or  partial  hypertrophy,  to  fibromata,  polypi,  &c.  The 
richness  ot  the  vascular  element  and  the  activity  of  its  circulation  dispose 
it  to  acute  or  chronic  inflammation,  complete  or  partial,  primitive  or  con- 
secutive. The  absence  or  rarity  of  cellular  tissue  explains  the  rarity  of 
suppuration,  apart  from  interstitial  phlegmons,  in  the  non-puerperal 
state.  The  ovary,  containing  more  cellular  tissue  and  an  almost  infinite 
number  of  little  vesicles,  destined  to  become  Graafian  vesicles,  is  on 
that  account  infinitely  more  hable  than  the  uterus  to  be  affected  with 
suppuration,  and  to  contain  purulent,  phlegmonous,  or  cystic  cavities. 
The  presence  of  a  mucous  membrane,  rich  in  vessels  and  in  glands, 
disposes  the  uterus  to  discharges  and  catarrhal  affections.  The 
mucous  membrane  of  the  cervix,  and  especially  that  of  the  os  externum, 
like  all  other  natural  orifices,  as  Tyler  Smith,  Bernutz  and  others  have 
pointed    out,  may  be  the  special  seat  of  various  eruptions,  herpetic. 


GENERAL    CHARACTERISTICS  235 

syphilitic^  ulcerous^  &c.  The  serous  peritoneal  fold  which  covers  the 
greater  part  of  the  external  surface  of  the  womb  exposes  this  organ  to 
serous  inflammations  and  their  consequences,  gives  to  peri-uterine  in- 
flammation the  special  characteristics  which  often  distinguish  it,  and 
is  the  frequent  cause  of  the  formation  of  adhesions  and  fibro-cellular 
bands  between  the  different  parts  of  the  uterine  system,  between  the 
ovaries  and  the  Fallopian  tubes,  and  between  the  Pallopian  tubes  and 
the  uterus,  &c.,  which  suspend  temporarily  or  definitively  the  accom- 
plishment of  their  functions,  dispose  to  phlegmons,  or  keep  up  the 
irritation  which  favours  the  persistence  of  inflammatory  centres. 

The  continuity  of  the  mucous  membrane  of  the  uterus  and  Fallopian 
tubes  with  the  peritoneal  serous  membrane  at  the  ostium  uterinum 
tends  to  propagate  the  inflammation  of  this  mucous  membrane  to  the 
peritoneum,  and  consequently  to  increase  the  evil  considerably.  This 
propagation  may  take  place,  whether  the  inflammation  be  spontaneous 
or  provoked,  and  this  consideration  ought  to  put  us  on  our  guard 
against  the  consequences  which  may  result  from  caustic  uterine 
injections,  even  where  they  do  not  penetrate  into  the  peritoneal 
cavity. 

The  vascular  activity  of  the  uterine  system,  with  the  periodic 
fluxions  which  take  place  in  it,  expose  the  whole  or  various  portions 
of  this  system  to  sudden  and  violent  sanguineous  fluxions,  to  consequent 
congestions,  to  hsemorrhages  internal,  external,  interstitial  or  apo- 
plectic; to  hypertrophies,  total,  partial  or  histogenetic ;  to  ovarian 
products,  especially  to  the  most  frequent  of  all,  multilocular  cysts. 

The  periodic  repetition  of  these  fluxionary  movements  at  the  men- 
strual period  and  their  return  during  pregnancy,  as  well  as  during 
uterine  diseases,  dispose  the  organ  to  fluxions,  congestions,  and  to  the 
pains  resulting  from  this  plethora  of  the  vascular  system,  and  lastly,  to 
the  persistence  of  these  morbid  states  if  critical  evacuations  do  not 
take  place. 

It  is  at  the  climacteric  especially  that  this  state  of  uterine  hypersemia 
is  developed  as  the  result  of  persistent  congestion  unrelieved  by  any 
critical  evacuations,  and  this  condition  not  only  constitutes  a  disease 
in  itself,  but  may  produce  many  kinds  of  diseases,  especially  of  a 
diathetic  nature. 

Sexual  relations  have  an  undoubted  influence  on  the  development 
and  perpetuation  of  uterine  diseases.  This  influence,  however,  has 
been  exaggerated;  it  is  not  responsible  for  all  the  diseases  attributed 
to  it.  West,  for  example,  seems  to  attribute  to  coition  imperfectly 
performed  an  exaggerated  influence  on  the  development  of  certain 
uterine  maladies.  It  is  nevertheless  certain  that  marital  intercourse 
not  only  may  produce  disease  but  keep  it  up.  As  to  the  part  which 
it  may  have  in  the  production  of  disease,  it  is  evident  that  excesses 
may  determine  permanent  congestion,  and  may  even  develop  complete 
or  partial  metritis,  followed  later  by  leucorrhcea,  granulations,  &c. 
There  is  also  no  doubt  that  although  coition  may  sometimes  be 
practised  at  the  menstrual  period  with  impunity,  such  imprudence  has 
often  caused  congestions,  more  or  less  serious  inflammations  and,  what 


236  UTERINE    DISEASES 

is  much,  more  dangerous,  sudden  suppression  of  the  sanguineous  dis- 
charge with  internal  haemorrhage  of  a  formidable  nature,  such  as  retro- 
uterine or  peri-uterine  hematocele. 

Generally,  however,  sexual  intercourse  acts  less  frequently  in  pro- 
ducing than  in  perpetuating  uterine  disease.  In  special  circumstances 
a  diathesis  may  become  localised  in  the  uterus  from  the  first  sexual  ex- 
citement. As  a  rulcj  however,  it  is  not  during  the  first  years  of  marriage 
that  the  greatest  number  of  uterine  diseases  are  developed,  but  only  after 
disorders  of  menstruation,  pregnancy,  abortion  and  labour.  In  such 
cases  coitus  is  neither  the  orighial  nor  secondary  cause  of  the  disease ; 
but  it  keeps  it  up,  prolongs  and  aggravates  it ;  I  have  occasion  to 
observe  this  every  day  with  regard  to  uterine  congestion.  It  even 
causes  relapses  after  a  cure  has  been  efl'ected,  therefore  under  certain 
circumstances  we  cannot  be  too  particular  in  forbidding  it. 

Pregnancy  and  labour  are  beyond  all  doubt  the  most  frequent  causes 
of  the  development  of  uterine  disease.  They  act  in  two  ways  :  as  predis- 
posing causes  by  the  important  modifications  imparted  to  the  organic 
structure,  and  as  exciting  causes  by  the  traumatism  which  they  produce. 
Aran  classes  two-thirds  of  all  utero-ovarian  disease  as  the  results  of 
pregnancy,  labour  and  abortion,  one-fourth  as  occurring  in  women 
who  have  had  children,  and  one-tenth  only  among  virgins  and  nulli- 
parEe.  Pregnancy  congests  the  uterus,  imparting  to  it  a  violet  hue ;  it 
increases  the  capacity  of  its  vascular,  and  especially  of  its  venous 
system.  It  hypertrophies  its  tissue;  in  short,  it  determines  the  in- 
crease, the  fall  and  the  renewal  of  its  mucous  membrane,  so  that  when 
the  organ  is  freed  from  the  product  of  conception  it  is  in  the  most 
favorable  circumstances  for  becoming,  or  rather  for  remaining,  diseased, 
for  this  state  of  hypertrophy,  however  shortly  prolonged  after  the  ex- 
pulsion of  the  foetus,  is  a  real  disease.  Labour  acts  as  a  real  traumatism, 
owing  to  the  mechanical  lesions  which  it  produces — the  contusion  and 
lacerations  of  the  cervix,  the  bleeding  wound  resulting  from  the  detach- 
ment of  the  placenta,  the  local  and  general  reaction  which  follow,  the 
uterine  and  peri-uterine  inflammation  which  may  be  developed,  the 
coincident  traumatic  fever  with  the  suppuration  and  gangrene  which  are 
sometimes  the  results  of  this  inflammation  and  which  we  may  say  are 
only  developed  in  this  single  case  of  uterine  disease.  The  results  of 
labour  have  no  less  influence  on  the  development  of  diseases  of  the 
womb.  The  least  complicated  morbid  condition  which  may  result  is 
the  persistence  of  uterine  hypertrophy  characteristic  of  pregnancy, 
owing  to  defective  retrograde  evolution  of  this  viscus.  It  is  diflBcult 
to  determine  the  true  causes  of  this  defective  involution,  but  it  is  pro- 
bable that  they  do  not  difi'er  from  those  which  produce  other  diseases 
resulting  from  labour,  such  as  rising  too  soon,  physical  fatigue,  resuming 
marital  intercourse  prematurely,  &c. 

After  abortion  the  uterus  is  even  more  disposed  to  become  diseased 
than  after  delivery  at  the  full  period  ;  not  to  acute  inflammations, 
suppuration,  gangrene,  &c.,  but  to  congestion,  engorgement  and 
hypertrophy,  especially  to  the  hypertrophy  referred  to  as  due  to  defec- 
tive involution.     It  seems  that  when  the  uterus  has  not  passed  through 


GENERAL    OHARACTEEISTICS  237 

the  various  phases  of  progressive  evolution  which  ought  to  be  com- 
pleted between  conception  and  parturition^  the  phenomena  of  natural 
involution  is  more  difficult  than  after  delivery  at  full  term,  and  that 
it  is  more  apt  to  be  arrested.  The  elements  of  muscular  tissue  as 
well  as  those  of  the  mucous  membrane,  when  suddenly  arrested  half 
way  when  in  full  activity  of  development,  have  no  tendency  to  pass 
through  the  modifications  of  atrophy,  fatty  degeneration  and  retro- 
gression which  characterise  involution ;  in  place  of  returning  rapidly 
and  completely  to  the  normal  dimensions  of  the  unimpregnated  uterus, 
they  preserve  the  volume  and  structure  appropriate  to  gestation,  which 
predispose  them  to  all  kinds  of  morbid  alterations. 

If,  then,  pregnancy,  labour  and  abortion  have  so  much  influence  on 
the  development  of  uterine  diseases,  what  must  the  result  be  of  cases 
of  pregnancy  rapidly  succeeding  one  another,  which  leave  the  uterus 
no  time  to  return  to  its  normal  condition  and  hinder  the  natural  work 
of  absorption  of  the  gestative  hypertrophy,  and  which,  by  keeping  the 
organ  in  a  state  of  congestion,  expose  it  to  the  invasion  of  diatheses  ? 
And  yet  I  must  admit  that  I  have  known  several  women  in  whom  the 
rapid  succession  of  pregnancies  (eight  or  ten  in  twelve  or  fifteen 
years)  has  not  produced  the  development  of  any  uterine  disease,  which 
is  one  of  the  most  striking  proofs  of  the  large  share  which  general 
affections  have  in  the  constitution  of  diseases  of  the  generative  system. 
In  others  I  have  observed  a  local  fatigue  produced  by  the  persistence 
of  the  tumefaction  of  this  organ,  and  general  consumption  due  to  the 
impoverishment  of  blood  caused  by  this  continual  return  of  gestation. 
I  have  therefore  concluded  that  the  development  of  uterine  disease 
in  these  women  was  due  rather  to  the  localisation  of  a  diathesis  than 
to  the  number  of  pregnancies,  which  seemed  merely  to  have  played 
the  part  of  exciting  cause. 

The  neglect  of  lactation  is  not  without  its  influence  in  impeding 
the  process  of  involution,  and  consequently  in  the  development  of 
uterine  diseases.  The  considerable  and  continuous  fluxion  wOiich 
lactation  keeps  up  in  the  breasts  probably  diverts  the  fluxionary  move- 
ments from  the  uterus,  and  therefore  helps  to  dissipate  congestion  and 
engorgement.  Lactation  is  also  useful  by  preventing  menstruation, 
with  the  fluxion  and  congestion  accompanying  it,  from  coming  to  add 
their  influence  to  that  of  defective  involution.  It  also  prevents  the 
premature  return  of  pregnancy  and  therefore  hinders  the  production 
of  the  morbid  tendency  just  pointed  out  as  the  consequence  of  a  rapid 
succession  of  pregnancies.  Investigations  made  on  this  subject  by 
Scanzoni  show  that  out  of  196  children  born  at  full  time  of  54  women 
suffering  from  uterine  affections  only  57  had  be^n  suckled  by  their 
mothers,  whilst  Aran^  tells  us  that  out  of  100  women  aft'ected  with 
diseases  of  the  womb  70  of  them  had  never  suckled. 

Sterility  may  preserve  women  from  many  uterine  diseases,  but  it 
does  not  guarantee  them  from  others,  especially  from  those  which  are 
dependent  on  the  development  and  localisation  of  diathetic  affections. 
Its  influence  is  all  the   more  liable  to  pass  unobserved  that  when  we 

'  Op.  cit.,  p.  93. 


238  UTERINE    DISEASES 

encounter  it  accompanied  with  uterine  disease  it  is  not  the  sterility 
which  has  caused  the  disease^  but  the  disease  which  has  caused  the 
sterility.  With  regard  to  this  matter  we  cannot  be  too  careful  to 
trace  the  cause  of  uterine  diseases  to  their  first  beginning  and  to  the 
general  and  local  conditions  which  may  keep  them  up,  for  in  removing 
them  we  may  be  able  to  cure  the  disease  as  well  as  the  sterility. 
Sterility  and  celibacy  can  only  be  classed  together  with  regard  to 
absence  of  gestation.  They  differ  entirely  in  other  respects.  In 
sterility  the  uterus  has  undergone  the  excitement  of  coitus,  whilst  the 
absence  of  this  cause  in  celibacy  seems  to  diminish  the  chances  of  the 
development  of  uterine  diseases.  Whether  that  be  so  or  not,  I  will 
sum  up  my  opinion  on  this  point  by  saying  that,  with  the  exception 
of  certain  menstrual  disturbances  and  the  general  disorders  dependent 
on  defective  function,  celibacy  does  not  seem  to  me  to  predispose  to 
diseases  of  the  uterus ;  but  it  does  not  prevent  them,  I  have  seen 
old  maiden  ladies  die  of  cancer  of  the  womb.  As  for  sterihty,  it  has 
seemed  to  me  oftener  to  be  the  effect  than  the  cause  of  disease.  In 
short,  in  considering  the  whole  of  the  utero-ovarian  system,  we  see 
that  the  diseases  of  one  part  of  this  system  may  become  the  causes  of 
disease  in  the  other  part,  sometimes  predisposing,  sometimes  exciting 
causes.  The  community  of  functions  involves  a  community  of  morbid 
susceptibilities.  The  same  Hnks  often  unite  these  various  organs  with 
regard  to  pathology  as  well  as  physiology.  Numerous  examples 
testify  to  the  reciprocal  action  which  diseases  of  the  ovaries  and  Fal- 
lopian tubes  exercise  on  the  uterus,  and  vice  versa.  The  covering  of 
all  these  organs  by  the  same  serous  membrane  is  an  additional  element 
in  favour  of  this  reciprocity  of  action.  Inflammation  is  propagated  by 
the  peritoneum  from  the  uterus  to  the  Fallopian  tube  and  to  the  ovary, 
more  frequently  still  in  the  contrary  direction.  The  adhesions,  the 
membranous  bands  which  form  pathological  connections  between  these 
different  organs,  are  not  without  their  influence ;  whether  in  imposing 
abnormal  conditions  in  the  performance  of  menstruation,  or  in  favour- 
ing the  escape  of  the  ovum  into  the  peritoneum  in  place  of  directing 
it  into  the  Pallopian  tube,  they  prepare  the  way  for  real  morbid 
conditions. 

We  know  very  little  with  regard  to  the  influence  which  diseases  of 
the  bladder  and  rectum  have  on  the  development  of  uterine  diseases. 
It  is  the  same  respecting  the  influence  exercised  by  diseases  of  the 
mammary  glands.  Our  knowledge  is  still  less  advanced  with  regard  to 
the  possible  influence  suggested  by  Aran  of  diseases  of  the  stomach 
and  liver,  heart  and  lungs,  in  the  production  of  these  morbid 
conditions. 

As  for  the  predisposing  general  causes,  the  circumstances  which 
have  more  or  less  direct  part  in  uterine  pathogeny,  are :  age,  tempera- 
ment, constitution,  and  especially  diathetic  affections  and  confirmed 
diseases. 

The  age  at  which  the  greatest  number  of  diseases  of  the  womb  has 
been  observed  is  certainly  that  of  sexual  activity — the  age  when  the 
generative  functions  are  performed  with  most  activity,  when  coitus  is 


GENERAL    OHAEAOTEttlSTICS  239 

most  frequent,  pregnancies  most  numerous.  In  300  cases  of  metritis 
Nonat^  observed  155  between  twenty  and  thirty  years.  Aran/  in 
100  cases  of  uterine  diseases,  had  62  in  women  between  twenty-one 
and  thirty  years.  That  does  not  mean  that  uterine  disease  may  not 
be  developed  at  other  ages  from  childhood  to  old  age.  It  is,  however, 
exceptional,  and  even  the  exception  may  be  remarked  by  its  preference 
for  certain  kinds  of  these  diseases  and  for  certain  organs  of  the  genital 
economy.  Thus  we  often  see  vaginal  leucorrhoja  in  children.  I  have 
seen  a  child  before  puberty  who  had  the  uterine  cavity  and  the  external 
half  of  the  Fallopian  tubes  filled  with  a  cheesy  substance  formed  of 
condensed  epithelial  cells,  showing  the  existence  of  serious  disease.  I 
have  seen  an  ovarian  cyst  in  a  little  girl  of  eleven  who  had  never  men- 
struated. Uterine  cancer  is  not  rare  in  the  last  period  of  the  life  of 
woman,  at  least  after  the  menopause. 

In  short,  every  age  has,  so  to  say,  its  special  predispositions.  When 
we  meet  with  disease  of  the  womb  in  a  child  it  affects  the  cervix,  which 
at  this  age  is  much  more  developed  than  the  body.  After  puberty 
and  before  coitus  it  is  the  body  which  is  most  frequently  affected. 
After  pregnancy  both  segments  of  the  organ  may  be  equally  affected. 
Virginity  does  not  exempt  the  young  girl  from  uterine  diseases. 
Bennet,  Aran  and  others  have  made  the  same  observation.  They 
are  liable  specially  to  fluxion,  congestion,  leucorrhoea,  uterine  catarrh, 
and  even  to  metritis,  but  less  so  than  married  women,  especially  women 
who  have  had  children.  The  starting-point  of  these  diseases  is  gene- 
rally some  disorder  of  menstruation,  the  predisposing  cause  being  a 
catarrhal  or  rheumatic  affection,  or  a  scrofulous  or  herpetic  diathesis. 
Diseases  of  the  body,  especially  of  its  mucous  membrane,  uterine 
catarrh,  and  leucorrhoea,  are  more  common  than  diseases  of  the  cervix 
amongst  virgins.  Diseases  of  the  cervix,  especially  ulcerations  and 
granulations,  although  sometimes  met  with  in  young  girls,  are  much 
more  frequent  in  married  women,  and  especially  in  multiparse,  in  whom 
the  cervix  has  been  exposed  to  the  contusions  incidental  to  excessive 
intercourse,  to  the  softening  of  pregnancy,  and  the  lacerations  of  labour. 
After  the  menopause,  uterine  diseases,  besides  being  rare,  may  exist  for 
a  long  time  without  causing  much  pain  or  producing  sympathetic 
disorders ;  in  fact  they  may  remain  latent  for  an  indefinite  time. 

We  know  nothing,  at  least  nothing  positive,  as  to  the  influence 
which  mode  of  life,  habit,  residence  in  town  or  country,  may  exercise 
on  the  development  of  these  afiections.  Whilst  admitting  that 
different  modes  of  life  exercise  various  kinds  of  influence,  I  cannot  say 
that  one  leads  more  frequently  to  disease  than  another.  Women  of 
weak  constitution  and  lymphatic  temperament  are  certainly  more 
exposed  than  others.  They  are  especially  exposed  to  the  protraction 
of  the  disease  owing  to  their  defective  reaction  and  to  the  predisposi- 
tion which  they  have  to  general  debility,  and  to  cachexia?  which  in  them 
more  than  in  other  women  are  the  rapid  consequences  of  the  impression 
produced  by  the  morbid  condition  on  the  organism.     Heredity  may 

'  Op.  cit.,  p.  59. 
^  Op.  cit.,  p.  99. 


240  UTERINE    DISEASES 

have  some  influence,  especially  in  such  diseases  as  cancer.  I  have 
seen  a  few  examples  of  this  kind.  I  have  also  observed  the  same  kind 
of  granulations  and  leucorrhoea  in  mother  and  daughter.  It  must, 
however,  be  admitted  that  direct  hereditary  influence  is  not  frequent, 
nor  is  it  clearly  proved  to  exist. 

It  is  not  so,  however,  with  the  various  diatheses  and  all  general 
affections,  which  undoubtedly  play  a  considerable  part  in  the  existence 
of  diseases  of  the  womb.  Some  authors,  such  as  Pidoux,  whose  ideas 
seem  to  have  inspired  Tillot's^  thesis,  exaggerate  this  influence  by 
invariably  attributing  to  diathetic  affections  the  chief  place  in  the 
etiology  of  uterine  diseases.  It  is  evident  that  the  uterus,  owing  to 
its  position,  structure  and  functions,  is  not  only  exposed  to  the  localisa- 
tion of  the  various  diatheses,  but  has  of  itself  a  tendency  to  originate 
chronic  disease.  We  cannot,  therefore,  admit  that  in  the  majority  of 
cases  uterine  lesions  are  only  secondary  symptoms  occurring  under  the 
influence  of  a  general  state,  nor  that  the  lesion  is  in  the  uterus  and 
the  disease  in  the  organism.  The  lesion  is  evidently  the  cause  of  all 
the  suff'erings  of  the  women.  Whether,  led  by  experience,  we  admit 
the  multiplicity  and  diversity  of  these  lesions,  or  whether  with  Lisfranc 
we  give  the  predominance  to  engorgement,  or  with  Yelpeau  to  de- 
viations and  granulations,  with  Dubois  to  catarrhal  phlegmasia,  or  with 
Bennet  to  metritis,  we  cannot  possibly  allow  that  the  serious  change 
which  this  lesion  produces  in  the  vitality  of  the  uterus  is  not  the  dis- 
ease properly  so  called,  and  consequently  the  cause  of  all  the  symptoms, 
general  and  local ;  nor  can  we  admit  with  Pidoux^  that  from  a  physio- 
logical point  of  view  the  uterus  and  its  annexes  are  only  the  centre  of 
the  general  changes  which  characterise  women  from  the  time  of  puberty, 
and  not  the  cause  of  them. 

Uterine  lesions,  whether  acute  or  chronic,  whether  connected  with 
a  diathesis  or  not — whether  they  be  functional,  organic,  or  due  to 
displacement — are  really  diseases  characterised  by  their  own  symp- 
toms requiring  direct  treatment.  Whilst  willing  to  admit  that  the 
diatheses  have  a  considerable  share  in  producing  them — a  much  greater 
share  than  the  local  conditions  just  enumerated — I  cannot  agree  with 
those  who  think  their  influence  exclusive. 

There  is  no  chronic  uterine  disease  that  is  entirely  free  from  the 
influence  of  some  diathesis.  We  cannot  even  make  an  absolute  excep- 
tion of  deviations  and  displacements,  as  Bund  pointed  out  in  a  paper 
read  before  the  Academy  of  Medicine  in  1849.  Thus,  supposing  that 
fluxion,  congestion,  chronic  inflammation,  hypertrophy  may  exist 
independently  of  a  diathetic  aft'ection,  it  is  not  the  less  certain  that 
these  morbid  conditions  are  in  some  degree  under  its  influence.  As  for 
engorgements,  leucorrhoea,  granulations,  ulcers,  cancers,  &c.,  they  are 
almost  always  dependent  on  a  diathesis  or  a  general  condition  not  less 
real. 

The  knowledge  of  this  diathesis,  by  enabling  the  physician  to  make 

'  De  la  lesion  et  de  la  maladie  dans  les  affections  chroniques  dii  systeme 
utdrin.     These  de  Paris,  32,  1860. 

^  Lettre  sur  la  fievre  puerperale,  1854 


GENERAL   CHARACTERISTICS  241 

a  general  diagnosis,  often  facilitates  the  local  one.  If  we  have  pre- 
viously discovered  or  if  we  recognise  the  actual  existence  of  a  marked 
diathetic  condition,  we  may  suspect  it  of  being  the  cause  of  the  evil. 
On  the  other  hand  we  must  beware  of  the  tendency,  which  was 
too  common  with  the  ancients,  of  attributing  the  lesion  to  a  constitu- 
tional taint  of  herpes,  syphilis,  scrofula  or  tubercle,  and  of  com- 
mitting Lisfranc's  error  of  mistaking  for  tubercle  some  quite  different 
cervical  lesion. 

Three  orders  of  facts  prove,  in  my  opinion,  that  the  diatheses  have 
a  more  or  less  important  share  in  the  existence  of  uterine  diseases,  and 
that  we  ought  to  take  them  into  account. 

Firstly,    the  coexistence  or  simultaneous    manifestations  of  these 
diathetic  conditions  in  the  uterus  and  in  other  organs.     Thus,  we  not 
unfrequently  see  uterine  leucorrhoea  associated  with  vesical  or  intes- 
tinal catarrh,  sometimes  even  with  bronchial  catarrh ;  eruptions  or 
ulcerations  on  the  cervix  with  herpes  on  the  vulva,  anus  and  other  parts 
of  the  body,  especially  on  the  other  natural  orifices ;  a  more  or  less 
painful  but  mobile  congestion  or  engorgement  of  the  uterus  with  rheu- 
matism or  erratic  pains  in  the  limbs,  even  visceral  pains  having  pre- 
viously manifested  themselves  in  the  same  patient  in  other  circum- 
stances ;  an  engorgement,  granulations,   ulcers  on  the   cervix,  with 
scrofulous  symptoms,  glandular  swellings,  ulcers,    impetigo,  &c.,  on 
other  parts  of  the  body.     These  coincidences  are  even  more  frequent 
in  syphilis.     They  may  also  be  seen    in    tuberculosis,    cancer,  &c. 
Secondly,  the  alternation  between    the  manifestation    and  especially 
the  exacerbation  of  the  uterine  disease  and  the  localisation  of  a  dia- 
thesis on  another  point.     This  phenomenon  is  observed  especially  in 
affections  the  seat  of  which  is  variable  and  mobile,  like  gout,  rheuma- 
tism, catarrh  and  herpes.     Just  as  in  a  man  I  have  seen  the  dartrous 
diathesis  localised  successively  on  the  glans,  urethra,  prostate,  bladder, 
ureter  and  kidney,  so  in  a  woman  I  have  seen  the  vulva,  vagina, 
cervix,  uterus.  Fallopian  tube,  or  ovary  attacked  simultaneously,  suc- 
cessively, or  alternately,  by  the  same  disease.     We  know  that  several 
cases  have  been  reported  lately  of  ovaritis  following  on  blenorrhagia, 
vaginitis  or  metritis,  just  as  orchitis  may  follow  urethral  blenorrhagia 
in  man.     I  have  seen  some  remarkable  cases  of  rheumatism  associated 
with  pain  and  swelling ;  of  neuralgia  depending  probably  on  the  same 
cause,  and  attacking  alternately  the  uterus,    ovary,  or  some  other 
viscus,  such  as  the  bladder,  the  stomach,  or  the  articulations,  the 
nerves,  fibrous  tissue,  aponeuroses,  or  lymphatic  ganglia.     Thirdly,  the 
proof  given  by  treatment,  a  sure  test  of  the  nature  of  disease.     How 
many  diseases  there  are,  apparently  simply  inflammatory,  which  have 
been  lessened  by  the  application  of  leeches,  rest,  baths  and  all  the 
other  means  of  antiphlogistic  treatment,  but  which  have  only  been 
cured  by  mineral  waters,  hydropathy  and  specific  treatment  appropriate 
to  the  character  of  the  evil ! 

The  diatheses  which  have  the  greatest  share  in  the  etiology  of 
chronic  diseases  of  the  uterus  may  be  either  hereditary  or  acquired. 
There  is  no  utility  in  distinguishing  them  nor  in  separating  them  from 

"]6 


242  UTERINE    DISEASES 

other  general  states  of  tlie  organism  which  may  have  a  similar  influence 
on  uterine  diseases.  We  may,  therefore,  class  in  this  category  all 
spontaneous  blood  disorders,  of  which  the  most  frequent  type  is 
chlorosis,  which  plays  so  important  a  part  in  female  pathology. 
Chlorosis  may  exist  already  in  a  woman  attacked  with  a  uterine 
disease.  It  may  even  be  the  cause  of  this  disease.  When,  however, 
the  latter  is  developed  the  chlorosis  generally  becomes  more  marked. 
In  some  cases  it  is  consecutive  to  the  lesion  which  was  primarily  pro- 
duced by  a  diathesis.  Deglobulisation  of  the  blood,  whether  it  be 
anterior,  concomitant  or  consecutive  to  the  disease,  whether  it  be 
cause,  effect  or  simple  coincidence,  does  not  the  less  frequently  accom- 
pany the  majority  of  uterine  diseases.-^ 

3,  The  nature  of  uterijie  diseases. — Most  frequently  the  diatheses 
have  not  been  the  exciting  cause  of  the  disease;  but  after  the  malady 
is  established  they  keep  it  up  and  really  give  it  its  character.  The 
malady  would  not  continue  to  exist  without  them  ,•  and  it  Avould  be 
impossible  to  cure  it  without  curing  them,  or  at  least  without  greatly 
modifying  them. 

After  the  diatheses  an  important  part  must  be  allowed  in  the  pro- 
duction and  chronicity — that  is  to  say,  in  the  nature  and  character  of 
uterine  diseases,  to  the  vitality  of  the  uterus,  or  rather  to  its  mode  of 
vitality,  to  the  elementary  physiological  acts  which  are  necessary  to 
the  accomplishment  of  its  functions,  to  the  facility  with  which  it  under- 
goes great  changes  and  remarkable  alterations  in  its  structure  and  in 
its  tissues.  Undoubtedly  the  majority  of  our  organs  have  in  the 
accomplishment  of  their  functions  a  continuity  of  action  which  would 
seem  to  make  them  more  liable  even  than  the  uterus  to  the  develop- 
ment of  chronic  diseases.  But  they  do  not  undergo  such  great  changes 
as  this  viscus  does  in  regard  to  the  innervation,  circulation  and 
change  of  tissue  of  the  organ.  It  is  just  because  of  the  extent  of  the 
oscillations,  the  return  of  these  periodical  acts,  the  temporary  and 
exceptional  activity  of  nutrition,  that  the  uterus  is  more  liable  to 
become  diseased  than  any  other  organ. 

Among  the  elementary  physiological  acts  which  are  connected  most 
frequently  with  the  production  and  aggravation  of  uterine  diseases,  we 
must  place  in  the  i5rst  rank  those  which  contribute  to  the  accomplish* 
ment  of  menstruation,  i.  e.  fluxion,  congestion  and  the  critical  evacua- 
tion of  blood.  These  acts  occur  in  almost  every  uterine  disease  as 
cause  or  complication.  The  physician  can  rarely  utilise  them.  He 
has  to  frustrate  their  influence,  moderate  their  manifestation,  combat 
their  effects.  These  three  acts,  as  we  shall  afterwards  see,  govern  each 
other  mutually  :  the  energy  of  the  fluxion  increases  the  intensity  of  the 
congestion,  and  consequently  the  amount  of  the  evacuation.  When 
the  balance  between  these  three  essential  elements  of  the  menstrual 
function  is  disturbed  disease  breaks  out. 

'  We  may  include  among  Llood  disorders  those  produced  by  general  miixsnia- 
tic  poisoning.  Paulin  Dnpuy,  Essai  cliniquc  sur  quelqucs  troubles  d'origine 
pahideenne  dans  les  fonctions  ffenitales  de  lafemvie.  These  de  Montpellier, 
1879. 


GENERAL    CHARACTERISTICS  243 

Fluxion  is  not  only  a  powerful  cause  in  the  production  of  uterine 
diseases,  it  not  only  prepares  the  way  for  congestion,  determines 
haemorrhage,  favours  fluxion,  aids  hypertrophy,  keeps  up  engorgement, 
furnishes  to  inflammation  its  natural  element,  but  it  hinders  treatment, 
prolongs  the  disease  by  the  periodicity  of  its  return,  increases  it  often 
by  its  intensity,  and,  in  short,  plays  the  principal  part  in  the  relapses 
which  too  frequently  follow  on  apparent  cure.  Aran  tells  us  that 
congestion  ought  to  he  considered  under  two  aspects  in  uterine  patho- 
logy :  sometimes  it  is  connected  with  an  actually  existing  disease  of 
the  uterine  system,  of  which  it  is  a  complication,  aggravating  or  pre- 
cipitating its  progress,  retarding  or  hindering  its  cure ;  sometimes  it 
exists  alone ;  sometimes  it  facilitates  the  development  of  new  affections. 
It  constitutes,  strictly  speaking,  an  element  in  uterine  disease,  and 
becomes  a  source  of  therapeutical  indications.  The  capital  indication 
in  fact  itself  includes  two  other  indications  : — 1,  to  diminish  the  con- 
gestive condition  at  the  menstrual  period;  2,  to  subdue  the  congestive 
condition  which  persists  after  any  period  till  the  appearance  of  the 
next.  The  san(/7nneous  discharge  may  be  either  defective  or  excessive. 
If  excessive  it  constitutes  a  disease  (menorrhagia)  ;  if  defective  it  pre- 
vents the  natural  crisis  from  taking  place,  and  leaves  the  uterus  con- 
gested, as  a  result  of  which  we  may  have  all  the  ills  which  I  have  just 
pointed  out  in  speaking  of  congestion. 

The  physiological  acts  which  take  place  in  the  uterus  at  every 
menstrual  period  are  produced  with  much  greater  intensity  at  every 
pregnancy.  Only  here  the  fluxion  and  congestion  of  the  organ  are 
continuous,  with  the  exception  of  some  augmentation  at  the  periods 
corresponding  to  the  menstrual  epochs.  The  sanguineous  discharge, 
haemorrhage,  depletion  of  the  congested  organ  only  occur  after  delivery. 
In  fact,  great  changes  are  effected  in  the  tissue  of  the  womb,  and  are 
added  as  new  causes  of  disease.  I  do  not  speak  only  of  the  changes 
of  tissue  which  are  produced  by  gestation,  but  also  of  those  which  arc 
effected  by  the  return  of  the  organ  to  the  state  of  vacuity.  To  the 
physiological  hypertrophy  of  pregnancy  succeeds  the  physiological 
atrophy  of  retrograde  evolution.  To  this  we  must  add  the  renovation 
of  the  mucous  membrane,  so  characteristic  of  uterine  life,  that  it  is 
produced  not  only  after  gestation  but  sometimes  after  menstruation 
alone. 

The  structure  of  the  uterus  is  in  accordance  with  its  special  func- 
tions. Its  tissue  is  characterised  by  the  presence  of  fibro-plastic 
elements,  hence  its  continual  tendency  to  hypertrophy.  This  tissue  is 
in  constant  process  of  organisation,  becoming  hypertrophied  by  preg-* 
nancy,  atrophied  after  delivery,  in  order  to  bring  the  organ  back  to  its 
normal  dimensions ;  in  place  of  the  stability  characteristic  of  the  other 
tissues,  it  has  a  continual  instability,  an  incessant  tendency  to  increase 
and  decrease.  This  tendency  is  indicated  by  the.  presence,  especially  in 
the  mucous  membrane,  of  the  organising  element  (the  flbro-plastic 
element),  and  is  coincident  with  analogous  physiological  tendencies, 
the  habit  of  fluxionary  movement,  alternating  congestion  and  deple- 
tion, &c. 


2it  UTERINE    DISEASES 

Now,  fluxlonari/,  plastic  and  hypertrophic  tendencies  characterise 
the  majority  of  uterine  diseases  as  they  characterise  the  functions  of 
the  organ.  Fluxion,  plastic  exuberance,  hypertrophy,  may  be  exhibited 
in  all  the  elements  at  once  or  only  in  some  of  them  ;  hence  the  fre- 
quency of  engorgements,  congestions,  fluxes,  tumours  or  homologous 
productions  of  all  kinds.  Localised  on  the  mucous  membrane,  very 
limited  in  extent,  spreading  to  the  most  superficial  part  of  the  papillte 
of  the  dermis,  to  its  vessels,  and  to  the  epidermis  covering  it,  this 
hypertrophy  gives  birth  to  the  granulations  so  frequently  found  in  the 
cervix.  This  same  hypertrophy,  spreading  to  the  healthy  granula- 
tions of  an  ulcer,  at  the  moment  when  the  work  of  cicatrisation  brings 
into  play  a  moye  or  less  energetic  increase  of  plastic  action,  produces 
granular  fungosities  more  frequently  there  than  anywhere  else.  When 
concentrated  in  the  organs  of  secretion,  it  develops  tumours,  cysts, 
and  follicular  polypi.  Localised  on  the  tissue  proper,  on  its  elements 
generally,  it  gives  rise  to  hypertrophy  properly  so  called ;  this  hyper- 
trophy may  extend  to  the  whole  uterus,  or  be  limited  to  the  body  or 
to  the  neck,  or  even  to  one  segment  of  the  neck  or  body,  to  one  of 
the  walls  of  the  latter,  or  to  one  of  the  lips  of  the  former.  When 
limited  to  certain  elements  it  produces  vascular  tumours^  fibromata,  or 
polypi. 

Hypertrophy,  besides  being  more  common  in  the  uterus  than  in  any 
other  organ,  has  the  tendency  to  spread  exclusively  to  one  or  other  of 
the  tissues  composing  the  womb,  and  to  a  limited  region  of  that  organ. 
In  this  way  the  uterus  remains  increased  in  size  owing  to  defective  in- 
volution after  delivery  ;  it  continues  to  increase  if  deviated  or  flexed, 
and  prolapsus  is  sufficient  to  double  its  volume.  On  the  other  hand, 
its  mucous  membrane  in  certain  menstrual  disorders  undergoes  an 
accidental  hypertrophy  and  exfoliation,  the  cervix  becomes  the  seat  of 
general  or  polypoid  excrescences,  the  follicles  form  glandular  polypi 
or  cysts,  the  tissue  proper  produces  fibrous  tumours,  &c. 

Thus,  by  its  structure,  by  its  functions  and  the  elementary  acts 
which  preside  over  their  performance,  the  uterus  differs  from  all  other 
organs,  in  being  in  constant  process  of  organisation,  always  liable  to 
change  of  volume  and  structure.  Instability  is  its  special  charac- 
teristic. In  its  tissue  the  equilibrium  established  between  the  nutri- 
tive movements  of  composition  and  decomposition,  assimilation  and 
disassimilation  is  not  stable  as  in  the  other  tissues ;  it  is  an  unstable 
or  momentary  equilibrium.  At  the  first  impulse,  it  is  disturbed 
and  falls  to  the  one  side  or  to  the  other.  This  tendency  to  adapt 
itself  to  the  part  which  it  has  to  play  in  menstruation,  conception, 
pregnancy  and  delivery  it  retains  in  all  circumstances  which  place  it 
in  somewhat  analogous  conditions.  Whether  its  cavity  be  filled  by 
mucus,  blood,  or  other  fluid,  or  by  a  solid  body  like  a  polypus; 
whether  a  tumour  such  as  a  fibroma  is  developed  in  the  inters! tices  of 
its  tissue,  or  a  foreign  ibody,  external  or  internal,  is  introduced  within 
its  orifices,  fluxion  is  determined,  the  uterus  becomes  congested,  hy- 
pertrophies and  contracts  in  order  to  expel  the  tumour  or  foreign  body, 
then  returns  to  its  normal  condition,  loses  its  hypertrophic  elements. 


geK^ebal  characteristics  245 

repairs  its  mucous  membrane ;  in  short,  it  passes  from  the  state  of 
vacuity  to  a  condition  similar  to  that  of  gestation,  once  more  returning 
to  that  of  vacuity. 

These  curious,  we  may  say  unique  properties  of  the  uterine  tissue 
seem  to  me  to  place  in  our  hands  the  key  to  a  mass  of  physiological, 
pathological,  therapeutical  phenomena,  which  can  be  utilised  for  the 
knowledge  and  treatment  of  uterine  diseases.  These  properties  evi- 
dently play  a  great  part  in  the  production  of  the  latter ;  and  it  is 
also  important  to  consider  them  again  with  regard  to  the  form  and 
course  which  they  give  to  these  diseases,  and  consequently  the  charac- 
teristic symptoms  which  they  often  communicate,  such  as  hyper- 
trophy, painful  contractions,  uterine  colics,  dilatation  of  the  cervix, 
&c.  &c. 

4.  The  knoioledge  of  these  properties  {and  especially  the  instabilltjf) 
of  the  uterine  tissue  is  important  in  relation  to  the  cure,  which  they 
may  either  hinder  or  facilitate  according  to  the  manner  in  which 
they  are  utilised  by  the  physician  in  his  treatment  of  the  disease. 
Hence  the  indication  for  action.  Lornet  induced  hypertrophy  as 
Simpson  did  by  means  of  metallic  stem  pessaries ;  sometimes  he  pro- 
voked dilatation  of  the  cervix  by  the  introduction  of  foreign  bodies, 
which  develop  uterine  contractions  and  so  facilitate  the  expulsion  of  a 
polypus,  the  enucleation  of  a  fibroid ;  sometimes  he  compressed  the  in- 
troverted uterus  by  means  of  an  air  pessary,  as  Tyler  Smith  did,  to 
provoke  simultaneously  a  dilatation  in  the  neck  and  a  contraction  in 
the  body,  both  alike  promoting  reduction.  Hence  also  the  indication 
for  action  in  the  opposite  direction,  using  means  to  overcome  morbid 
hypertrophy,  by  placing  the  organ  under  the  same  conditions  as  when 
it  spontaneously  undergoes  retrograde  evolution  after  delivery.  Hence 
the  innocuity  of  intra-uterine  cauterisation  with  the  crayon  when  there 
is  abundant  leucorrhoea  or  considerable  granular  fungosities ;  for  the 
mucous  membrane  is  not  affected,  or  it  is  easily  repaired  at  the  points 
which  may  appear  to  have  been  too  much  acted  on  by  the  caustic. 
Hence  the  innocuity  of  the  actual  cautery  applied  to  the  cervix  or  to 
its  tissue ;  for  its  raucous  membrane,  even  if  severely  affected,  which 
is  not  often  the  case,  has  a  manifest  tendency  towards  regeneration. 
Hence  also  the  resolution  induced  by  these  cauterisations  in  chronic 
congestion,  engorgement  and  hypertrophy,  by  promoting  absorption 
and  by  giving  an  impetus  to  nutrition  in  that  direction. 

I  shall  not  dwell  longer  on  the  tendency  to  hypertrophy,  the  plastic 
exuberance,  the  faculty  of  regeneration,  which  characterise  the  uterus 
anatomically,  physiologically  and  pathologically.  I  shall  have  occasion 
to  recur  to  it  throughout  this  work  when  speaking  of  membranous 
dysmenorrhoea,  granulations,  fungosities,  vegetations,  follicular  hyper- 
trophy, follicular  tumours  and  polypi,  uterine  hsemorrhoidal  tumours, 
partial  hypertrophies  of  the  mucous  membrane,  hypertrophies  of  the 
tissue  of  the  body,  and  of  the  cervix,  fibroma,  subperitoneal  fibroma, 
sarcomatous  polypi,  &c. 

I  must,  however,  remark  that  this  tendency  to  vegetation  is  not 
limited  to  the  uterine  tissue.     There  is  the  same  tendency  in  the  Fal- 


2.46  UTEEINE    DISEASES 

lopian  tubes  and  in  the  ovaries,  especially  under  a  cystic  form  in. har- 
mony with  their  structure.  The  same  tendency  is  to  be  found  in  the 
vagina  and  vulva,  with  regard  to  which  I  shall  point  out  some  facts 
not  generally  known,  showing  that  the  vagina  shares  the  hypertrophic 
tendencies  of  the  uterus.  Por  the  present  I  shall  only  remark  that 
the  hypertrophic  tendency  shown  in  the  highest  degree  in  the  mucous 
membrane,  and  in  the  muscular  tissue  of  the  uterus  and  in  ovarian 
cystic  formations,  may  be  propagated  successively  to  all  the  other  parts 
of  the  generative  economy,  or  separately  to  the  various  tissues  which 
enter  into  their  composition,  either  by  simple  extension,  by  participa- 
tion in  a  great  increase  of  physiological  activity,  or  by  community  of 
morbid  influences. 

I  think  I  have  given  a  sufficiently  detailed  description  of  the  general 
and  local  circumstances  presiding  over  the  development  of  uterine 
diseases  to  characterise  these  diseases  sufficiently  from  this  point  of 
view. 

Several  of  the  characteristics  which  remain  to  be  described  are  simply 
deduced  from  these  circumstances  ;  for  undoubtedly  till  we  reach 
them  we  cannot  penetrate  to  the  true  nature  of  the  diseases  in 
question. 

5.  Uterine  diseases  intanahly  have  a  double  morhid  nature,  general 
and  local.  I  cannot  share  the  opinion  of  Aran,^  who  thinks  that  the 
differences  between  the  various  morbid  states  are  gradually  effaced,  and 
that  after  a  certain  time,  in  place  of  the  original  disease,  we  have  to 
contend  with  a  number  of  local  and  general  symptoms,  requiring, 
according  to  circumstances,  the  most  varied  treatment.  Uterine  dis- 
eases always  preserve  their  twofold  character ;  as  diseases  of  the  womb, 
they  often  differ  from  all  other  organic  disease ;  as  diathetic  diseases 
they  have  more  or  less  in  common  with  other  general  affections.  They 
have  also  a  double  set  of  symptoms  :  local  symptoms,  dependent 
on  the  sensibility  and  vitality  special  to  the  uterus ;  and  general  sym- 
ptoms, dependent  on  the  diathetic  affection  or  on  the  sympathetic 
reaction  excited  in  the  organism  by  the  local  lesion. 

Uterine  diseases  may  assume  different  forms  according  to  the  manner 
in  which  these  symptoms  present  themselves.  In  this  respect^  groups 
of  symptoms,  whilst  offering  infinite  varieties  in  the  mode  of  associa'> 
tion,  nevertheless  present  themselves  under  two  principal  forms,  which 
ought  always  to  be  present  to  the  mind  of  the  physician  that  he  may 
be  on  his  guard  against  errors  of  diagnosis  :  in  one,  local,  in  the  other, 
general  phenomena  predominate. 

The  form  most  easily  diagnosed  is  evidently  that  in  which  there  is 
?L  predominance  of  local  Sf/mptoms.  These  are  symptoms  always  linked 
together  in  a  somewhat  similar  way.  First,  hypogastric  pains  in- 
creased by  exercise,  fatigue,  constipation  and  the  approach  of  the 
menses,  and  localised  often  in  the  left  iliac  region.  Lumbar,  inguinal 
and  femoral  pain  occur  afterwards.  Leucorrhcea  and  menstrual  dis- 
orders sometimes  appear  very  early,  at  the  commencement  of  the 
disease  with  the  hypogastric  pains,  or  they  may  gradually  follow  these 

1  Op.  cit.,  p.  169. 


GENERAL   CHARACTERISTICS  247 

first  local  symptoms.  It  is  evident  that  uterine  disease  arising  in 
this  way  cannot  fail  to  strike  the  patient  and  to  be  diagnosed  by  the 
physician,  especially  if  these  local  symptoms  become  more  and  more 
marked,  if  the  hypogastric  pains  assume  the  character  of  colics,  if  the 
persistence  or  exacerbation  of  pain  in  the  left  iliac  region  draw  the 
attention  to  the  appendages,  and  especially  if  vesical  tenesmus  and  con- 
stipation are  added  to  the  uterine  symptoms  properly  so  called.  Very 
often,  however,  uterine  diseases,  in  place  of  betraying  their  presence 
in  away  likely  to  attract  attention,  remain  undiscovered  for  a  longer  or 
shorter  time  owing  to  the  obscurity,  or  it  may  be  the  complete  absence 
of  all  local  symptoms.  In  such  a  case  the  cry  of  the  suffering  organ 
does  not  come  from  the  uterus,  but  from  the  whole  organism.  It  is 
the  result  of  the  influence  invariably  exercised  by  the  womb  on 
the  whole  economy  and  the  sympathetic  reaction  stirred  up  by  the 
apparently  insignificant  disorders  of  this  organ.  Every  time  that  a 
change  takes  place  in  the  womb,  that  its  functions  are  modified  by 
puberty,  menstruation,  conception,  pregnancy,  the  menopause,  or  that 
its  vitality  is  impaired  or  its  structure  affected  by  some  malady,  the 
harmony  of  the  whole  system  is  disturbed.  More  than  any  other 
organ  it  is  liable  to  disease,  and  more  than  any  other  organ  it  reacts 
on  the  whole  economy. 

The  second  form,  with  predominance  of  general  symptoms  may  be  so 
marked  as  completely  to  efface  all  local  phenomena.  We  can  easily 
understand  how  the  sole  existence  of  general  symptoms  modifies  the 
symptomatic  expression  of  a  local  malady,  deceiving  the  patient  as  to 
the  seat  of  disease  and  leading  the  physician  astray  in  his  investiga- 
tions unless  he  is  on  his  guard.  I  have  already  said  that  these  sym- 
ptoms in  order  of  frequency  are  :  dyspepsia  in  every  form  and  degree> 
with  its  inevitable  result  defective  nutrition,  emaciation,  decline,  de- 
globulisation  of  the  blood,  discoloration  of  the  skin  and  mucous  mem- 
brane, palpitations  of  the  heart,  feeling  of  suffocation,  cough  and 
nervous  symptoms  of  various  kinds.  In  most  cases  local  symptoms 
are  not  entirely  wanting,  but  they  are  insignificant  and  intermittent 
and  tolerated  by  the  patient  from  habit,  or  from  energy  of  character, 
or  her  attention  may  not  be  attracted  to  them  owing  to  their  vague 
character.  They  must  therefore  be  discovered  by  the  physician.  It 
is  surprising  what  characteristic  symptoms  pass  unnoticed  by  patients 
unless  we  are  particular  in  our  inquiries.  This  is  the  case  with  leu- 
corrhcea;  many  women  think  it  is  almost  a  normal  phenomenon, 
especially  if  they  have  been  chlorotic  in  their  youth  and  the  white  dis- 
charge has  replaced  the  sanguineous  one,  or  if  the  leucorrhcca  precedes 
or  follows  the  menstrual  hcemorrhage  and  is  not  abundant.  Now,  it 
cannot  be  too  distinctly  stated  that  normally  there  is  no  white  nor 
transparent  discharge,  and  that  when  such  exists,  whatever  may  be 
the  general  or  local  cause,  it  ought  necessarily  to  suggest  the  idea  of 
a  genital  malady,  and  that  functional  disturbance  of  the  digestive  organs 
is  not  suflficient  to  cause  it ;  in  fact  it  is  not  the  dyspepsia  which  pro- 
duces the  leucorrhcca,  but  the  leucorrhcca  which  causes  the  dyspepsia* 
When  the  malady  presents,  itself  under  this  form,  with  predominance 


248  UTERINE    DISEASES 

of  general  symptoms^  it  rarely  happens  that  certain  characters  of  these 
very  symptoms  do  not  lead  the  physician  into  the  right  track  ;  suck 
are  the  coexistence  of  nervous  phenomena  in  the  lower  limbs,  nervous 
cough,  facie,<t  uterina  and  hysterical  symptoms,  especially  a  feeling  of 
faintness  felt  by  the  patient  when  standing. 

It  is  remarkable,  as  I  have  already  said,  that  between  these  two 
forms  there  is  another  in  whicli  local  and  general  symptoms  are  con- 
cealed by  a  morbid  increase  of  flesh,  which  gives  the  patient  a  fictitious 
look  of  health,  although  there  is  very  real  and  sometimes  very  acute 
general  suffering  and  local  pain.  I  have  seen  several  cases  of  this 
kind  where  the  commencement  of  the  malady  was  mistaken  for 
pregnancy. 

6.  The  complexity  of  symptoms  more  or  less  vague  seems  to  characterise 
certain  morbid  conditions  of  the  womb.  Uterine  maladies  differ  in 
character  not  only  by  the  predominance  of  general  or  local  symptoms, 
but  also  by  the  presence  or  absence  of  a  certain  symptom  characteristic 
of  a  certain  morbid  condition. 

Sometimes  the  morbid  state  is  easily  determined ;  it  is  accompanied 
by  a  certain  acuteness ;  its  characters  are  well  defined,  its  symptoms 
have  one  meaning.  Sometimes  after  a  certain  period,  the  acute 
feature  having  entirely  disappeared,  the  primitive  form  gives  place  to  a 
congestive  condition  accompanied  by  several  concomitant  disturbances, 
each  of  which  is  insufficient  to  characterise  a  malady,  but  which  taken 
together  are  serious  enough,  and  yet  there  is  no  symptom  predominant 
enough  to  indicate  to  the  physician  the  dominating  element  of  this 
morbid  condition,  the  one  with  which  treatment  should  commence.  It 
is  this  condition  to  which  Pidoux  has  given  the  name  of  Bysmetria. 
I  know  that  these  complex  and  half-effaced  morbid  conditions  are  not 
described  in  uterine  pathology,  but  they  exist  in  practice.  In  such 
cases  we  must  attack  the  various  elements  of  the  disease  successively, 
at  the  risk  of  being  accused  of  merely  treating  symptoms ;  we  often 
end  by  simplifying  the  malady  and  discovering  the  true  starting  point 
of  the  chief  troubles.  I  admit  that  complexity  is  not  special  to  uterine 
diseases  more  than  to  those  of  other  organs,  but  it  must  be  taken  into 
account  in  making  the  diagnosis.  Amongst  all  these  associated  morbid 
elements  we  must  distinguish  those  which,  although  blended  in  one 
disease  in  the  same  organ,  yet  merit  the  name  of  complex  diseases, 
from  others  which,  by  remaining  always  distinct,  even  when  they  spread 
to  portions  of  the  same  economy,  ought  to  be  designated  under  the 
name  of  complications. 

7.  The  complications  of  uterine  diseases  are  variable.  They  are  not 
only  the  sympathetic  phenomena  and  the  general  symptoms  occasionally 
developed  ;  they  consist  also  in  the  disorders  of  various  organs  making 
part  of  the  uterine  system  and  in  the  organic  disorders  of  other 
systems. 

The  various  organs  composing  the  uterine  system  are  seldom  affected 
singly,  or  at  least  they  do  not  remain  long  without  being  attacked  by 
some  malady  which  complicates  the  primitive  one.  When  the  ovaries 
are  inflamed  or  transformed  into  cysts  it  is  seldom  that  there  is  not 


GENEEAL    CHARAOTEHISTICS  2^0 

fluxion,  congestion,  engorgement  of  the  uterus.  When  the  uterus  is 
diseased  it  is  perhaps  rarer  still  for  the  peritoneum,  Fallopian  tubes 
and  ovaries  not  to  be  afPected  by  the  same  disease,  or  at  least  by  the 
inflammation  or  congestion  accompanying  it.  Mayer,  of  Berlin,  in  a 
paper  entitled  '  Quelques  mots  sur  la  sterilite,'^  affirms  that,  out  of 
263  cases  of  women  affected  with  sterility,  and  having  some  uterine 
ailment,  35  had  fluxions  or  versions  with  the  following  complications  : 
13  had  endometritis,  8  chronic  ovaritis,  7  ovarian  tumours,  4  hyper- 
trophy of  the  uterus,  2  uterine  polypi,  1  a  fibroid  tumour.  Sometimes 
there  are  complications  which  aggravate  the  evil  and  increase  the 
difficulties  of  the  case. 

Organs  unconnected  with  the  uterine  system  may  also  be  more  or  less 
aff'ected.  Thus,  in  100  uterine  diseases,  Aran"  has  counted  the  follow- 
ing as  complications  :  18  cases  of  inflammation  of  the  appendages,  31 
of  catarrh,  25  of  pulmonary  phthisis,  9  of  cardiac  disease.  I  think, 
however,  that  these  complications  are  not  so  frequent  as  these  statistics 
(which  probably  are  hospital  statistics)  would  lead  us  to  suppose.  In 
short,  complication  like  complexity  is  a  certain  fact  in  uterine  dis- 
eases which  must  be  taken  into  account.  The  various  elements  of 
this  morbid  association  must  be  attacked  simultaneously  or  successively. 
Sometimes  the  complication  has  not  been  discovered  till  the  uterus 
improves.  Then  the  disease  of  the  ovary  or  peritoneum  which  had 
passed  unnoticed  is  distinctly  recognised  in  such  a  case.  This  disease 
claims  our  attention  and  supplies  the  major  indications.  Such  sur- 
prises can  only  be  avoided  by  the  physician  making  a  very  careful  and 
minute  examination. 

8.  Uterine  diseases  are  essentially  chronic.  The  course  which 
characterises  the  majority  of  uterine  diseases  can  be  easily  deduced 
from  the  long  details  into  which  I  entered  when  treating  of  their 
etiology.  With  the  exception  of  traumatic  and  puerperal  diseases 
there  is  perhaps  no  uterine  malady  that  is  not  very  slowly  developed. 
A  great  number  even  of  the  diseases  of  the  uterus  and  appendages 
which  attack  women  after  delivery  would  not  make  their  appearance 
if  the  organ  or  organism  were  not  predisposed.  Therefore,  even 
when  we  see  diseases  such  as  these  accompanied  by  a  group  of 
acute  symptoms,  we  may  say  that  all  uterine  diseases  are  primarily 
chronic. 

They  owe  this  character  of  chronicity  to  the  share  which  the  dia- 
theses have  in  their  constitution  and  to  the  anatomical  and  physiolo- 
gical conditions  of  the  uterus  on  which  I  have  insisted  so  much.  In 
some  circumstances,  however,  acute  symptoms  occur  at  the  commence- 
ment of  a  uterine  disease,  at  other  times  later.  But  these  acute 
symptoms  are  merely  associated  with  the  invasion  of  the  malady  or 
may  be  exacerbations  of  it.  The  disease  continues  to  pursue  a  chronic 
course.  Its  chronicity  is  kept  up  by  the  majority  of  the  causes  which 
induce  acute  phenomena.  The  periodical  recurrence  of  fluxion  and 
congestion  hinder  cure  and  keep  up  the  evil.     If  they  exceed  their 

'  Virchow's  Archiv,  Sept.,  1856. 
2  Op.  cit.,  p.  155. 


250  UTERINE    DISEASES 

ordinary  proportions  or  if  they  are  accompanied  by  some  unusual  cir- 
cumstance this  is  sufficient  to  revive  inflammation  or  give  to  other 
morbid  elements  renewed  nourishment  which  rekindles  the  acute 
symptoms.  A¥e  may  say  that  the  periodical  return  of  subacute 
symptoms  is  characteristic,  as  well  as  chronicity,  of  uterine  diseases. 

9.  The  difficulty  of  cure  is  not  less  characteristic  of  these  diseases. 
Undoubtedly  some  are  incurable.  It  is  also  certain  that  cure  may 
easily  be  effected  when  the  disease  is  simple  and  acute  or  at  least 
recent ;  even  then  it  necessitates  a  longer  treatment  than  if  situated 
elsewhere.  Whilst,  however,  the  majority  of  uterine  diseases  are 
curable,  we  must  admit  that  they  are  less  so  than  the  majority  of  dis- 
eases of  other  organs.  I  have  already  said  that  spontaneous  cures 
do  not  occur.  I  may  add  that  under  the  influence  of  the  most 
rational  treatment  a  cure  is  only  effected  very  slowly.  What  retards 
it  is  the  slowness  and  chronicity  of  the  disease,  the  part  played  by  the 
diathesis,  the  recurrence  of  menstruation  which  keeps  up  the  disease, 
the  unfavorable  oscillations  which  this  periodical  fluxion  establishes 
between  the  curative  and  the  morbid  tendencies,  and  the  fixed  exacer- 
bations and  relapses  due  to  menstruation  or  to  other  causes. 

The  menopause  may  lead  to  a  return  of  health,  but  even  this  result 
unfortunately  does  not  always  happen.  Tluxions,  though  irregular, 
are  not  less  common  when  kept  up  by  an  old  lesion,  and  as  they  are 
not  always  accompanied  by  evacuation,  they  have  all  the  more  tendency 
to  keep  up  congestion  during  a  certain  time,  that  is  till  the  patient  has 
really  entered  on  old  age. 

Therefore,  even  when  under  the  influence  of  an  appropriate  treat- 
ment the  malady  has  begun  to  yield,  amelioration  often  remains  sta- 
tionary, and  much  perseverance  and  energy  are  required  before  the  end 
is  reached.  A  cure  cannot  be  said  to  have  been  effected  unless  it  has 
stood  the  test  of  time  and  the  recurrence  of  several  menstrual  periods. 
Subjective  symptoms,  such  as  lumbar  pain  and  disorders  of  innerva- 
tion, may  persist  for  a  long  time  even  after  the  disappearance  of  objec- 
tive symptoms.  Treatment  must  be  directed  against  them  uninter- 
ruptedly, for  they  too  may  cause  relapses  owing  to  the  debilitated  state 
in  which  they  keep  the  organism. 

Let  me  add  that  it  is  necessary  to  be  on  one's  guard  against  the 
appearance  of  cure  of  uterine  diseases,  in  the  course  of  which  another 
malady  occurs.  When  an  acute  disease  is  developed  concurrelitly 
with  the  malady  of  the  womb,  the  uterine  symptoms  disappear  in 
some  measure  in  virtue  of  the  law,  duohus  lahoribus  simul  obortis  non 
in  eodem  locO)  vehementior  ohscurat  alterum  ;  but  they  return  after  the 
cure  of  the  acute  disease  which  had  temporarily  suspended  them. 
Where  a  chronic  disease  occurs  the  two  maladies  exist  and  progress 
simultaneously,  for  the  uterine  disease  has  weakened  the  constitution, 
and  this  impoverishment  only  gives  a  greater  hold  to  the  other  morbid 
act.  Only  a  sort  of  equilibrium  is  established,  in  virtue  of  which 
sometimes  the  one  sotnetimes  the  other  has  the  advantage;  in  such 
Cases,  if  the  pathological  condition  endanger  life,  we  must  respect  the 
uterine  symptoms  for  fear  that  an  exacerbation  of  this  morbid  condi- 


GENERAL   OHAEACTEEISTICS  251 

tioii  should  hasten  a  fatal  termination.  All  practitioners  agree  as  to 
the  necessity  of  expectant  treatment  in  such  cases. 

Two  other  reasons  contribute  towards  diminishing  the  chances  of 
cure  in  the  case  of  uterine  diseases  which  present  a  marked  character- 
istic of  chronicity ;  the  first  is  that  patients  have  become  so  habituated 
to  their  sufferings,  and  have  learned  to  tolerate  them  so  well,  that  they 
are  unwilling  to  submit  to  the  exigencies  of  a  treatment  the  strict 
observance  of  which  is  often  the  only  guarantee  of  success;  for  example, 
in  certain  diseases  it  is  difficult  to  prevent  marital  intercourse,  in  others 
to  prevent  the  fatigue  entailed  by  social  life.  The  second  is  the 
defective  nature  of  the  diagnosis  and  treatment ;  the  defective  nature 
of  the  diagnosis  arises  from  a  want  of  necessary  precision,  from  omit- 
ting something  in  an  examination,  from  failing  to  interpret  correctly 
the  symptoms  observed,  or  from  the  difficulty  in  unravelling  the 
various  phenomena  in  complex  cases ;  defective  treatment  is  the  result 
of  a  defective  diagnosis,  of  the  irregularity  with  which  patients  carry 
out  their  treatment,  and  in  some  cases,  e.g.  deviations,  it  is  the  result 
of  the  insufficiency  of  our  therapeutical  means. 

If  we  consider  the  various  circumstances  I  have  just  enumerated  we 
can  easily  understand  how  little  chance  there  is  of  spontaneous  cure  in 
uterine  diseases,  and  how  necessary  is  an  intelligent  medical  inter- 
ference, which  must  be  both  active  and  persevering  if  a  cure  is  to  be 
effected. 

10.  Before  finishing  this  summary  description  of  uterine  diseases, 
I  must  refer  to  ilieir  dwersity,  and  point  out  that  mode  of  classifica- 
tion which  seems  to  present  them  in  the  most  natural  order. 

After  all  that  I  have  said  hitherto  with  regard  to  the  crude  sys- 
tematisations  that  have  been  made  in  uterine  pathology,  and  as  to 
reducing  all  morbid  conditions  of  the  womb  to  one  disease,  the  reader 
must  have  seen  that  I  have  throughout  this  work  tried  to  give  proofs 
of  the  existence  of  mani/  morbid  conditions  differing  as  to  cause, 
nature,  seat,  syjnptoms,  indications  and  treatment.  I  admit  that  the 
difference  is  not  always  well  marked,  that  the  same  causes  sometimes 
produce  different  effects,  that  these  morbid  conditions  are  associated 
in  place  of  being  isolated  and  distinct ;  that,  however,  does  not  prevent 
the  existence  of  a  natural  diversity.  The  recognition  of  this  diversity 
is  the  best  basis  of  diagnosis  and  therapeutic  indications. 

Only  we  must  remember  the  meaning  of  the  words  uterine  disease, 
and  the  limits  which  exist  between  health  and  disease  in  the  generative 
organs. 

Is  every  abnormal  phenomenon,  every  material  change  a  disease  ?  Is 
there  any  essential  and  primary  affection  connecting  these  lesions?^ 
Every  abnormal  phenomenon,  every  material  disorder  not  involving 
disturbance  of  the  uterine  or  other  functions  is  an  exceptional  fact^  but 
does  not  deserve  the  name  of  disease.  If  the  uterine  functions  are 
disturbed,  however,  and  if  this  disorder  leads  to  othersj  there  is  disease* 
As  to  the  diversity  of  uterine  diseases,  here  as  elsewhere  we  must  apply 

'  Boudct,  Bedlierchcs  sur  la  nature  ct  Ics  causes  dcs  afcciions  uUrinei: 
Theses  de  Paris,  1857. 


252  UTERINE    DISEASES 

the  natural  method  in  order  to  distinguish  the  various  morbid  condi- 
tions which  have  a  common  seat.  Now,  it  is  evident  that  there  are 
physiological  disorders  of  the  uterus  which  may  react  on  the  whole 
organism ;  and  that  there  are  affections  of  the  whole  economy  which 
may  be  localised  in  the  uterus.  There  are  changes  of  organic  tissue; 
there  are  displacements  or  changes  with  regard  to  the  relationship  of 
this  and  neighbouring  organs.  Lastly,  there  are  diseases  depending  on 
one  or  other,  or  on  both. 

The  nature  of  diseases  ought  to  form  the  basis  of  the  principal 
divisions.  The  variety  of  form  and  seat,  the  diversity  of  the  parts  or 
elements  of  the  organ  affected  by  the  disorder,  is  the  basis  of  the 
secondary  divisions.  jNTow  in  placing  ourselves  at  this  double  point  of 
view,  we  at  once  recognise  the  existence  of  uterine  diseases  that  are 
fundamentally  different.  Sometimes  they  are  functional  disorders, 
menstrual  troubles  more  or  less  serious,  derangements  in  the  expres- 
sion and  sequence  of  the  physiological  phenomena  characterising  the 
vitality  and  destination  of  the  organ.  Sometimes  they  are  simply  dis- 
placements, changes  of  position  or  direction,  resulting  from  an  altera- 
tion in  the  statical  conditions  of  the  organ,  and  causing  a  simple 
modification  in  its  topographical  anatomy  and  in  its  relations  to  the 
neighbouring  organs.  At  other  times  the  alterations  are  not  limited  to 
simple  anatomical  or  physiological  disorders ;  they  affect  the  organ  in 
its  vitality,  in  its  nutrition,  often  even  in  its  structure  and  in  the  com- 
ponent elements  of  its  tissue.  Sometimes  the  development  of  a  modi- 
fication of  local  vitality  or  the  localisation  in  the  uterus  of  a  general 
affection  communicate  to  its  functions  a  characteristic  disturbance  or 
determine  in  the  organ  the  manifestation  of  very  characteristic  patho- 
logical acts,  and  finally  the  realisation  of  a  fixed  morbid  condition. 
Sometimes  a  real  diathesis  invades  the  organ  at  once,  or  profits  by  a 
simple  pathological  act  to  fix  itself  there,  communicating  to  the 
morbid  condition  the  anatomical  and  pathological  characters  which 
distinguish  it,  and  lead  to  its  recognition  on  any  other  organ.  Lastly, 
persistent  alterations  of  tissue  or  the  formation  of  new  tissue,  whether 
homeomorphous  or  heteromorphous,  produce  in  the  organ  functional 
disturbances  and  often  pathological  processes,  constituting  the  chief 
phenomenal  expression  of  the  disease. 

It  is  plain,  therefore,  that  uterine  diseases  can  be  distinguished  by 
the  same  terms  that  are  used  in  general  and  special  pathology,  viz.  as 
anatomical  lesions,  vital  affections,  organic  disorders. 

11.  The  diversity,  however,  is  accompanied  ly  complexity,  through 
the  association  of  diseases.  Eegarded  from  the  same  point  of  view, 
uterine  maladies  will  be  seen  to  preserve  their  simplicity  less  than  those 
of  any  other  organ.'  Besides  the  characteristic  complexity,  we  may 
remark  the  tendency  in  these  diseases  to  be  linked  to  each  other ;  so 
that  after  a  certain  time  it  is  more  or  less  difficult  to  discover  which  is 
the  original  malady,  and  to  determine  whether  the  principal  indication 
for  treatment  lies  in  the  primary  or  in  the  subsequent  lesions.  Some- 
times in  fact  displacements  cause  menstrual  disorders  and  pathological 
effects,  more  or  less  complex ;  sometimes  menstrual  disorders  (conges* 


GENERAL    CHARACTERISTICS  253 

tion  and  increased  weight  of  the  organ)  produce  displacements.  A.fc 
other  times  diathetic  disorders^  organic  lesions,  neoplastic  tumours 
determine  functional  disturbance.  On  the  other  hand,  functional  dis- 
turbance after  a  certain  time  is  followed  by  diathetic  disorders  and  the 
development  of  tumours.  Displacements  tend  to  produce  simple  patho- 
logical processes,  as  well  as  the  manifestation  of  the  most  complex  morbid 
conditions  and  the  development  of  organic  lesions.  The  worst  is,  that 
when  these  diseases  are  associated  it  is  difficult  to  determine  which  of 
them  causes  the  most  serious  symptoms,  and,  therefore,  which  ought 
to  be  first  attacked.  For  example,  it  is  not  often  that  simple  devia' 
tions  cause  real  pain,  but  it  frequently  happens  that  they  are  acconi' 
panied  by  metritis,  pelvic  peritonitis,  &c.,  and  that  consequently  they 
occasion  serious  accidents. 

We  must  always  try  to  discover  the  link  which  connects  pathological 
processes,  and  to  determine  which  of  the  morbid  acts  takes  precedence  of 
the  others  at  a  given  moment. 

13.  In  order  to  classify  the  various  diseases  according  to  their 
natural  order  of  stcccessioti,  we  must  try  to  put  those  foremost  which 
occur  most  frequently  alone,  and  which  are  seen  more  frequently  and 
uncomplicated  for  a  longer  time  than  others,  passing  afterwards  to 
those  which  are  composite  and  to  those  whose  composition  becomes 
more  and  more  complex,  and  at  last  reaching  the  most  composite  of 
all,  in  each  of  which  we  may  say  that  the  whole  of  uterine  pathology 
may  be  concentrated. 

I.  Classified  according  to  this  principle,  functional  disturbances  take 
the  first  rank,  %.  e.  diseases  in  which  functional  disturbances  play  the 
chief  part  and  form  the  principal  element  of  indication.  Whether 
idiopathic  or  symptomatic,  menstrual  disorders  are  real  diseases,  for 
they  seriously  disturb  the  health.  Menstruation  may  be  considered  as 
a  delivery  in  miniature.  Now  menstruation  and  delivery  are  two 
functions  unlike  any  others ;  in  fact  they  resemble  pathological  rather 
than  physiological  acts  :  hence  their  tendency  to  produce  disease.  All 
functional  disturbances  are  connected  with  menstruation.  The  cata- 
menia  may  be  defective,  excessive  or  abnormal,  giving  rise  to  amenor^ 
rhea,  including  retention  and  deviation  of  the  menses ;  dysmenorrhea^ 
including  uterine  neuralgia ;  and  lastly,  menorrhagia  and  metrorrhagia, 
in  which  the  sanguineous  discharge  is  not  only  a  critical  evacuation 
but  a  real  haemorrhage  (internal  haemorrhage  is  described  with  pelvic 
tumours).  Not  only  are  disorders  of  menstruation  the  most  frequent 
diseases,  but  they  so  often  complicate  uterine  maladies  and  have  so 
large  a  share  in  their  chronicity  or  in  their  exacerbations,  that  we  must 
always  take  them  into  account  and  discover  when  they  are  the  cause  of 
these  diseases,  that  we  may  obtain  the  clue  to  an  important  part  of 
general  treatment.  For  these  reasons  we  ought  to  commence  uterine 
pathology  with  the  diagnosis  and  treatment  of  the  disorders  of  men- 
struation. 

II.  Next  to  functional  disorders,  I  have  placed  changes  of  position 
the  chief  characteristic  of  which  is  an  alteration  in  the  situation 
direction  and  form  of  the  uterus.     I  know  that  these  morbid  con- 


254  UTEEINE    DISEASES 

ditions  are  seldom  as  simple  as  has  been  supposed,  their  principal 
symptoms  being  as  often  dependent  on  their  complications  as  on 
themselves ;  sometimes  they  may  be  the  result  of  preceding  morbid 
conditionSj  such  as  congestion,  engorgement,  and  hypertrophy ;  whilst 
in  their  turn  they  may  produce  leucorrhcea,  granulations,  ulcers.  But 
whatever  may  be  the  accompanying  complications,  whatever  may  be 
the  displacement,  there  are  cases  in  which  a  change  in  the  conditions 
of  the  equilibrium  of  the  uterus  plays  the  principal  part  and  may  be 
disengaged  from  all  concomitant  phenomena.  These  changes  are  of 
four  kinds  :  1.  Blsj^ilacements,  including  elevation,  descent,  and  hernia  ; 

2.  I)eviatio7i8,  designated  under  the  names  of  inclinations,  or  versions; 

3.  Mexions,  or  changes  in  the  relative  position  of  the  two  portions  of 
the  uterus;  4.  Lastly,  Liversions,  or  changes  in  the'relative  position  of 
the  external  and  internal  surfaces  of  the  organ. 

III.  In  proceeding  from  the  simple  to  the  composite,  we  encounter 
in  the  third  place  morlid  states  wi'thout  neofjlasm.  I  give  this  name 
to  affections  generated  by  a  simple  morbid  act,  local  or  general,  dia- 
thetic or  not  diathetic,  but  neither  accompanied  by  persistent  changes 
of  tissue  nor  by  the  formation  of  new  elements.  These  maladies  are 
often  designated  by  the  name  of  vital  affections.  The  first  of  all  these 
morbid  conditions,  those  which  help  to  produce  or  complicate  the 
others,  are,  in  the  order  of  their  production  :  fluxion,  characterised  by 
a  temporary  movement  more  or  less  vigorous,  single  or  repeated  ;  con- 
gestion, characterised  by  the  persistence  of  local  hyperemia ;  engorge- 
ment, resulting  from  the  repetition  or  persistence  of  the  preceding 
states  and  from  effusion  of  the  serous  elements  of  the  blood  into  the 
affected  tissues.  Then  follows  inflammation,  which  borrows  its  prin- 
cipal elements  from  the  preceding  morbid  conditions,  and  is  character- 
ised by  its  tendency  to  suppuration  or  hyperplasia,  and  which  occupies 
a  large  share  in  the  pathology  of  the  uterus  as  of  that  of  all  other 
organs.  I  have  classed  with,  inflammation  of  the  uterus  that  of  its 
appendages,  the  surrounding  peritoneum  and  cellular  tissue ;  i.e.  the 
morbid  states  known  under  the  names  of  metritis,  endometritis,  para- 
metritis, and  perimetritis.  I  have  not  even  separated  ovaritis,  inflam- 
mation of  the  Pallopian  tubes  and  peri-uterine  inflammation  from 
metritis,  because  these  morbid  conditions  are  often  associated  and 
influence  each  other  mutually;  because  when  the  one  exists  the 
development  of  the  other  is  to  be  feared;  and  lastly,  because  they 
occasion  the  same  indications  and  necessitate  almost  the  same  treat- 
ment. The  morbid  conditions  which  follow,  whilst  often  connected 
with  inflammation  as  cause,  effect,  or  complication,  are  generally 
dependent  on  a  diathesis.  They  are  :  leucorrJuea,  liypertrojphy,  granu- 
lations, and  fungous  growths,  ulceration  and  ^dcers.  The  importance 
of  hypertrophy,  though  for  long  misunderstood  can  hardly  be  over- 
estimated. 

IV.  In  the  fourth  rank  I  have  placed  organic  alterations,  i.e.  the 
morbid  conditions  characterised  by  a  persistent  alteration  of  tissue  and 
differing  from  each  other  according  as  they  are  produced  without  the 
formation  of  new  elements,  or  with  development  of  anatomical  ele- 


GENERAL    CHAEAOTERISTICS  255 

ments  having  no  analogy  with  the  special  elements  of  the  uterine 
tissue.  The  first,  corresponding  to  homomorphous  productions, 
inclnde  Jil/rot/iata,  interstitial  fibrous  bodies  or  sub-peritoneal  tumours, 
whether  pediculated  or  not,  andpoli/pi,  mucous  or  epithelial,  follicular, 
fibrous  or  vascular;  with  which,  as  far  as  diagnosis  and  treatment  are 
concerned,  ?/ioles  are  naturally  connected.  The  second,  corresponding 
to  heteromorphous  productions,  are  tubercle  and  cancer  with  all  their 
varieties  of  form  and  of  locality  ? 

V.  Lastly,  I  have  arranged  in  a  fifth  category  the  organic  altera- 
tions of  the  appendages  and  the  abdominal  or  pelvic  tumours  resulting 
from  their  formation.  This  category,  from  which  ovaritis  and  peri- 
metritis have  previously  been  separated,  includes  only  two  important 
morbid  conditions:  1.  Peri-uterine  hematocele,  which  is  as  much  con- 
nected with  diseases  of  the  appendages  as  with  peri-uterine  maladies, 
since  it  derives  its  origin  so  frequently  from  haemorrhages  of  the  ovary 
and  Fallopian  tubes.  2.  Ovarian  tumours,  among  which  multilocular 
cysts  take  the  first  place  from  their  importance  and  the  recent  progress 
made  in  their  treatment,  and  tumotors  of  the  Fallopian  tubes,  connected 
as  they  are  with  the  interesting  history  of  the  migration  of  the  ovum 
and  of  extra-uterine  pregnancy.  Sterility,  its  diagnosis  and  treatment, 
form  the  natural  termination  to  this  last  chapter  and  to  the  knowledge 
of  all  the  diseases  previously  studied. 

I  have  thought  it  useless  to  reproduce  the  statistics  of  uterine  dis- 
eases given  by  some  gynecologists;  for  they  do  not  even  give  an 
approximate  idea  of  the  relative  frequence  of  these  various  diseases.  If 
it  is  a  question  of  hospital  practice,  either  a  special  class  of  cases  is 
seen,  e.  g.  venereal  affections,  or  only  the  most  serious  cases  or  cases 
requiring  operation :  for,  as  a  rule,  patients  will  not  go  to  an  hospital 
while  they  can  move  about.  Hospital  practice,  however,  never  can  be 
a  fair  sample  of  the  innumerable  variety  of  uterine  diseases  to  be  found 
in  any  country.  A  general  practitioner  having  the  entire  practice  of  a 
district  in  his  hands  would  perhaps  be  able  to  furnish  more  correct 
statistics.  But  probably  even  he  would  only  see  the  most  serious  cases ; 
the  majority  of  the  less  serious  would  forego  treatment  under  such  cir- 
cumstances, while  others  would  address  themselves  to  specialists  in  a 
neighbouring  town.  It  is  almost  impossible  for  any  statistics  of 
private  practice  to  give  even  an  approximate  idea  of  the  relative  fre- 
quency of  different  uterine  diseases.  This  difficulty  is  quite  indepen- 
dent of  the  diseases  themselves ;  as  for  myself,  I  could  not  give  such 
statistics.  I'ormerly  I  had  a  great  many  cases  of  metritis,  leucorrhcea, 
polypi,  &c. ;  now  I  hardly  have  one,  the  reason  being  that  women 
affected  with  these  diseases  are  more  or  less  successfully  treated  by 
young  practitioners.  Now,  on  the  contrary,  I  have  great  numbers 
of  incurable  diseases,  cancers,  enormous  fibromata,  and  ovarian  cysts ; 
patients  coming  to  me  from  great  distances  because  the  treatment  of 
other  doctors  has  been  unsuccessful.  Such  cases  not  only  occupy 
much  more  space  in  my  statistics  than  they  formerly  did,  but  much 
more  than  they  ought  to  do  from  their  relative  frequency.  It  is  the 
same  with  several  other  diseases,  fortunately  not  incurable  like  those 


256  UTERINE   DISEASES 

just  named,  but  more  difficult  to  cure  than  a  number  of  others,  such 
as  flexions,  perimetritis,  peri-uterine  adenitis,  phlegmons  of  the  broad 
ligament,  hematoceles,  &c.,  as  well  as  others  such  as  mechanical  dys- 
menorrhoea  and  the  various  diseases  which  result  in  sterility.  These 
cases,  which  were  almost  entirely  absent  from  my  first  statistics,  occupy 
an  important  place  in  my  later  ones,  since  my  successful  treatment 
of  a  large  number  of  cases  became  known  to  the  pubhc,  and  has  been 
a  fact  recognised  by  the  profession. 


PAET   II 

UTEEINE    DISEASES    IN    DETAIL 
CHAPTER  I 

FITNCTIOKAL  DISOEDEES. — MEN8TEUATI0N — AMENOEEHffiA — EETENTION  OF  THE 
MENSES — DEVIATION  OF  THE  MENSES  AND  SUPPLEMENTAEY  MEN8TEUATI0N 
— DTSMENOEEHCEA — UTESINE   NEUEALGIA — UTEEINE   H^MOEEHAOB. 

Strictly  speaking,  there  is  only  one  function  with  the  disorders  of 
which  we  are  concerned,  viz.  menstruation;  and  this  function  can  only 
be  deranged  in  three  ways  :  it  may  be  defective,  excessive,  or  dis- 
ordered. 

Menstruation  is  a  flow  of  blood  from  the  uterine  cavity,  occurring 
in  an  intermittent  manner,  generally  at  regular  intervals,  except 
during  pregnancy  and  lactation,  from  the  age  of  puberty,  i.e.  from  12 
to  15,  to  that  of  the  climacteric  from  45  to  50.  Its  regular  recur- 
rence shows  an  aptitude  for  reproduction  besides  indicating  the  most 
favorable  periods  for  conception. 

The  mean  duration  of  the  intercalary  or  intermenstrual  period 
being  about  a  month,  these  haemorrhages  have  been  designated  the 
monthly  periods  or  menses,  or  the  catamenia ;  their  regular  recurrence 
at  fixed  times  has  led  to  the  term  monthly  periods ;  the  dominant  fact 
of  the  discharge  to  that  of  the  catamenia ;  and  the  idea  of  the  evacua- 
tion being  favorable  to  the  general  health  to  that  o^  jmrgatio  menstnia. 

Menstruation  is  the  function.  The  words  monthly  period,  menses, 
catamenia,  &c.,  designate  the  external  phenomenon  which  characterises 
it. 

Disorders  of  menstruation 

Menstruation  deserves  the  attention  of  the  physician  as  a  means 
towards  the  interpretation  of  uterine  diseases;  it  is  a  term  of  com- 
parison. If  menstruation  has  rightly  been  called  a  pregnancy  in 
miniature,  we  may  say  that  it  offers  an  epitome  of  several  uterine  dis- 
eases taken  as  a  whole  or  in  some  of  their  elements.  Menstruation 
also  deserves  attention  because  it  may  become  a  cause  of  diseases  of 
the  womb  ;  it  has  a  considerable  share  in  uterine  etiology  as  well  as  'w\ 
uterine  pathology ;  for,  although  itself  a  physiological  act,  it  places 
the  organ  which  is  the  seat  of  it  in  conditions  different  from  the  equili- 
brium which  is  one  of  the  characteristics  of  health  in  all  the  other 
organs.     Menstruation  ought  also  to  excite  our  interest  because,  by 

17 


258  UTEIIINE    DISEASES    IN    DETA.1L 

its  disorders,  it  always  discloses  the  existence  of  a  uterine  disease. 
Often  we  have  no  other  means  of  arriving  at  a  diagnosis.  In  women 
suffering  from  uterine  disease,  the  menses  either  produce  pain,  cause 
its  reappearance,  or  increase  it ;  they  last  a  longer  or  shorter  time  than 
in  the  normal  condition,  and  often  are  so  irregular  that  patients  cannot 
fix  the  time  of  their  recurrence.  Menstruation  is  also  worthy  of 
our  serious  consideration  on  account  of  the  aggravation  of  the 
local  condition  which  it  does  not  fail  to  produce  in  uterine  dis- 
eases, as  well  as  of  the  interruptions  to  treatment  which  it 
necessitates.  Lastly,  menstruation  itself  may  be  disordered ;  in  its 
evolution  and  recurrence  it  is  subject  to  more  or  less  serious  derange- 
ments which  constitute  those  uterine  diseases  which  will  first  occupy 
our  attention. 

In  order  correctly  to  appreciate  the  disorders  of  menstruation  we 
must  follow  this  function  throughout  its  whole  course  from  beginning 
to  end.  It  may  fail  in  establishing  itself,  or  great  difBculties  may 
present  themselves  in  its  establishment,  or  it  may  disappear  for  some 
time.  When  established  and  regulated,  circumstances  may  occur  to 
suspend  its  course,  or  if  it  continue  to  recuf  regularly,  it  may  be  accom- 
panied by  more  or  less  serious  accidents  at  every  period.  The  mens- 
trual discharge  may  also  be  deranged  with  regard  to  the  quantity  and 
quality  of  the  fluid  excreted.^  The  ordinary  division  of  the  disorders 
of  menstruation  which,  as  I  have  said,  may  be  excessive,  defective  or 
deviated,  is  very  practical.  The  catamenia  may  not  appear  at  the 
period  of  life  when  we  naturally  expect  them,  or  they  may  be  sup- 
pressed after  a  variable  time ;  or  the  discharge  may  take  place  with 
difficulty ;  or  it  may  be  excessive  in  quantity,  or  it  may  recur  too 
frequently.  Hence  three  great  classes  of  menstrual  disorders,  respond- 
ing to  which  are  often  three  kinds  of  capital  indications. 

1.  Amenorrhcea  including  :  retained  menstruation  and  deviated  men- 
struation. 

2.  HysmenorrTioRa,  to  which  we  may  add  membranous  dj/smenorrhcea 
and  uterine  neuralgia. 

3.  Uterine  hemorrhages,  including  menorrhagia  and  metrorrhagia. 
These  menstrual  disorders  are  sometimes  symptomatic,  sometimes 

idiopathic.  It  is  of  great  importance  to  distinguish  the  one  class 
from  the  other,  and  this  is  what  I  shall  endeavour  to  do  in  the 
description  I  am  about  to  give  of  them. 

It  is  easy  to  prove  that  the  disorders  of  menstruation,  considered  as 
a  whole,  are  of  great  practical  importance.  West^  rightly  remarks 
that  the  changes  oi puberty  in  the  girl,  like  those  of  dentition  in  the 
child,  are  not  effected  suddenly,  but  are  prolonged  over  a  period  of 
some  months,  during  which  time  diseases  frequently  occur. 

The  tables  of  mortality  show  that  this  period  is  more  fatal  to  girls 
than  the  preceding  one,  if  we  compare  the  numbers  of  deaths  in  the 
two  sexes.    Quetelet  and  Smits^  have  shown  that,  whilst  in  infancy 

^  Menstruatio  aboletur,  imminuitur,  intenditur,  depravatur.     (Astriic.) 

2  Diseases  of  Women,  4th  edition.     London,  1879,  p.  26. 

3  Sur  la  reproduction  et  la  mortaliU  de  I'homme.    Brussels,  1832. 


MENSTEUATION 


259 


mortality  is  equal  in  the  two  sexes  or  greater  amongst  boys,  it  is^  on  the 
contrary,  greater  amongst  girls,  in  the  proportion  of  1"28  to  1  from 
the  fourteenth  to  the  eighteenth  year,  and  that  it  descends  in  the  four 
following  years  to  1*05  for  girls  against  1  for  boys. 

The  anxiety  of  parents  at  the  approach  of  this  period  is  therefore 
natural.  Moreover,  it  is  not  without  reason  that  this  anxiety  increases 
in  proportion  to  the  delay  experienced  in  the  first  appearance  of  the 
menses.  Whitehead  has  proved  that  the  danger  of  accidents  is  greater 
when  the  menses  are  delayed  than  when  they  are  precocious,  and  the 
researches  made  by  West  confirm  this  opinion.  The  following  in- 
teresting statistics  are  given  us  by  Whitehead  •} 


First  Menstruation. 

No.  of  Cases.           Unfavorable  Cases. 

Proportion. 

From  10  to  14  years  .     .     . 
„     15  „  16    „       ... 
„     17  „  18    „      ... 
„     19  and  upwards     .     . 

1141 

1178 

892 

239 

224 
324 

247 
97 

19-63 
18-75 
27-69 

40-58 

Total    ..... 

3450 

1 
892                  22-30 

Whilst  delay  in  the  appearance  of  the  catamenia  seems  to  increase 
the  chances  of  accidents  which  follow  the  establishment  of  this  func- 
tion, its  precocity  seems  to  indicate  in  the  uterus  an  activity  favorable 
h)  the  development  of  certain  diseases,  particularly  of  organic  diseases, 
or  rather  of  cancer.^  Kussmaul,^  having  come  across  a  case  of  cancer 
of  the  ovary  in  a  child  of  two  years  with  the  development  of  a  girl  of 
twelve  or  fifteen,  asked  himself  if  there  was  any  connection  between 
precocious  puberty  and  ovarian  disease.  After  numerous  researches 
he  arrived  at  negative  results  for  serous  or  dermoid  cysts,  but  positive 
for  sarcomatous  or  cancerous  neoplasms.  Out  of  six  cases  of  this  kind 
which  he  collected  in  three  there  was  a  history  of  precocious  puberty. 
EUeaume*  made  similar  researches  with  regard  to  the  influence  of 
precocious  menstruation  on  the  development  of  uterine  cancer,  and 
found  that  out  of  twenty-eight  cases  of  this  disease  menstruation  had 
occurred  in  nineteen  before  the  age  of  fourteen  years. 


Amenorrhcea. 

Amenorrlma  (absence  of  menstruation),  if  we  consider  the  etymology 
of  this  word,  includes  the  tardy  appearance  of  the  menses,  their 
premature  cessation,  and  amenorrhcea  properly  so  called.^ 

'  Treatise  an  Abortion  and  Sterility,  p.  48.     London,  1847. 

-  I  have  often  noticed  that  women  affected  with  organic  lesions  of  the 
uterus  and  ovaries  had  menstruated  prematurely  and  abundantl}'. 

3  W'ilrzbiirger  medicinische  Zeitschrift,  t.  iii,  1862 ;  Archives  gencralcs  de 
tncdecine,  fevrier,  1863,  t.  i,  p.  224. 

■*  L' Association  mcdicale,  15  fevrier,  1863,  p.  55. 

^  According  to  Etmiillcr  (Castelli  Lexicon),  the  disappearance  of  the  men.scs 


260  UTEEINE  DISEASES   IN   DETAIL 

The  delay  in  the  appearance  of  the  menses  may  depend  merely  on 
the  defective  establishment   of  this  function.     Sometimes  ovulation 
takes  place  although  there  is  no  uterine  haemorrhage.     At  other  times 
there  is  delay  in  the  sexual  development  or  a  suspension  of  the  repro- 
ductive functions,  either  spontaneous  or  occasional,,  by  some  malady. 
Lastly,  there  may  be  absence  of  the  uterus  or  imperforation  of  this 
organ,    causing  retention  of  the  menses;    therefore  I   cannot  too 
strongly  advise  the  physician  to  assure  himself  of  the  normal  con- 
formation of  the  genital  organs,  in  certain  critical  circumstances  in 
which  a  girl  who  has  never  menstruated  may  be  placed ;  for  instance, 
on  the  eve  of  marriage.     I  knew  a  young  woman  in  this  position : 
the  family  physician  was  consulted,  and  in  place  of  dissuading  the 
parents  from  marriage  he  was  imprudent  enough  to  advise  it,  under 
the  pretext  that  conjugal  relationship  would  not  fail  to  provoke  the 
catamenial  flow.     Unfortunately,  I  discovered  some  years  later  com- 
plete absence  of  the  body  of  the  uterus,  so  that  I  could  give  no  hope 
of  children  to  the  unfortunate  parents  who  consulted  me.     I  found, 
however,  that  the  ovaries  were  present  in  this  young  woman ;  so,  too, 
were  the  menstrual  molimen  and  sexual  desire.     I  have  had  occasion 
to  see  other  cases  of  the  same  kind.^ 

The  premature  cessation  of  menstruation  may  also  coincide  with  the 
cessation  of  ovulation  or,  which  is  rarer,  may  precede  it.  It  seldom 
occurs  without  some  exciting  cause,  either  general  or  local.  When 
genuine,  it  is  neither  accompanied  by  disorders  nor  by  congestive 
phenomena  in  the  utero-ovarian  economy. 

Amenorrhcea,  strictly  speaking,  is  the  absence  of  menstruation  after 
one  or  more  monthly  periods.  Whether  it  disappear  after  some  time 
under  the  influence  of  the  efforts  of  nature  or  of  an  appropriate  treat- 
ment, or  whether  it  persist  to  an  age  when  it  becomes  definitive,  being 
transformed  into  the  menopause,  it  may  constitute  an  anomaly  rather 
than  a  morbid  condition.  Amenorrhoea  is  normal  during  pregnancy 
and  lactation.  In  every  other  condition  it  is  either  an  accidental  ab- 
normal condition,  or  the  symptom  of  a  morbid  condition,  or  a  real 
disease. 

Diagnosis. — Symjitomatic  amenorrlima  depends  on  various  patho- 
logical conditions  of  the  uterus  or  of  the  body  generally.  As  regards 
the  uterus,  these  are  :  malformation,  either  congenital,  such  as  I  have 
described,  or  acquired,  as  I  shall  have  occasion  to  refer  to  in  speaking 
of  retention  of  the  menses ;  inflammation,  acute  or  chronic,  but  espe- 
cially acute  inflammation  of  the  uterus  or  of  its  appendages ;  rarely 
organic  lesions  of  the  womb ;  oftener  those  of  the  ovaries.  If  depen- 
dent on  the  general  organism,  the  menses  may  be  suppressed  by  acute 
diseases,  although  this  seldom  happens  when  they  occur  at  the  com- 
mencement of  a  disease ;  they  are,  however,  almost  always  suppressed 

{suppressio  lyiensium)  should,  be  distinguished  from  their  delayed  appearance 
(emansio  onensmm) . 

^  Courty,  Demande  en  nullite  cle  mariage  fondce  sior  le  defaut  de  caracteres 
sexuels  feminins ;  consultation  medico -14 gcde  et  considerants  du  jugement. 
Montpellier  medical,  t.  xxviii,  p.  473.  Montpellier,  1872.  Annales  de  Gyne- 
cologic, t.  ii,  pp.  325,  410.     Paris,  1874. 


AMENOERH(EA  261 

towards  the  decline  of  tlie  disease  or  during  convalescence.^  In  chronic 
diseases  the  menses  diminish,  become  irregular,  and  finally  are  sup- 
pressed, as  the  weakness  increases  and  hectic  fever  makes  its  appear- 
ance and  the  prognosis  becomes  more  grave ;  it  is  what  happens  every 
day  in  tuberculous  and  cancerous  affections,  in  organic  diseases  of  the 
heart  and  in  Bright's  disease,  in  cirrhosis  of  the  liver  when  dropsy 
commences,  in  some  nervous  affections,  in  anasmia,  in  chlorosis,  in 
polyuria,  diabetes  and  obstinate  diarrhoea.^  In  symptomatic  amenor- 
rhoea  the  cause  may  disappear  whilst  the  amenorrhoea  persists. 

IdiopafMc  amenorrhoea  is  that  in  which  more  or  less  prolonged  sus- 
pension and  cessation  of  menstruation  depend  on  a  cause  exerting  a 
direct  influence  on  this  function.^  Any  general  disturbance  may 
produce  it  by  arresting  the  functions  of  the  ovary  or  uterus,  by  pre- 
venting fluxion  from  taking  place,  by  arresting  congestion  and  haemor- 
rhage, by  turning  aside  the  synergetic  movements  which  establish  the 
molimen  and  cause  the  discharge  of  blood.  It  is  probable  that  ovula- 
tion cannot  continue  to  be  eff'ected  unless  uterine  hsemorrhage  is  pro- 
duced. The  impression  of  cold  in  any  form  and  on  any  part  of  the 
body — for  instance,  a  cold  sitz-bath  or  foot-bath,  a  change  of  linen,  a 
fall  or  blow,  the  disturbance  caused  by  a  fit  of  indigestion,  by  blood- 
letting, an  emetic,  pain,  or  fright — are  the  most  common  causes  of 
this  derangement.  Uterine  torpor,  congenital  or  acquired,  and  pre- 
mature atrophy  of  the  womb  encourage  this  action.  Anxiety,  grief, 
change  of  habits  and  residence,  as  happens  for  instance  with  girls 
who  are  sent  to  school,  a  sedentary  life  like  that  in  convents,  and  im- 
prisonment following  an  active  and  free  life,  often  produce  a  more  or 
less  serious  and  prolonged  disturbance  in  menstruation.  The  facility 
with  which  this  function  is  afi'ected  by  slight  causes  is  also  common  to 
most  of  the  other  acts  of  reproduction ;  the  impressionability  of  the 
generative  system  seems  to  be  greater  than  that  of  the  other  organic 
systems,  so  great  that  Eaciborski  has  seen  occasion  to  attribute  amenor- 
rhoea to  the  simple  fear  of  pregnancy  after  illicit  intercourse,  or  to  the 
great  desire  of  having  children  after  prolonged  steriHty,  and  this  he  has 
designated  amenorrhoea  from  psychical  causes.  Whether,  however, 
the  impression  is  produced  on  some  part  of  the  body  (sudden 
chill,  intestinal  parasites)  or  on  the  brain  (vivid  moral  impressions), 
it  is  by  a  kind  of  reflex  action  on  the  uterus  that  amenorrhoea 
is  produced,  which  has  led  some  writers  to  call  it  sympathetic 
amenorrhoea. 

'  Heravd,  Be  I'influence  des  maladies  aigues  fehriles  sur  les  regies.  Raci- 
borski,  Traite  de  la  menstruation. 

^  Becquerel,  op.  cit.,  t.  ii,  p.  406. 

2  It  is  evident  that  cither  the  ovary  or  uterus  may  he  affected,  hence  the 
division  of  amenorrhoea,  according  to  Racihorski,  into  ovarian  or  radical  and 
uterine.  The  first  may  be  organic  or  functional.  Functional  ovarian  amenor- 
rhoea, caused  by  a  kind  of  torpor  of  the  ovaiy,  is  true  amenorrhoea ;  it  may 
consist  either  in  delays  or  in  complete  amenorrhcea.  To  be  still  more  exact,  we 
must  distinguish,  from  this  point  of  view,  three  kinds  of  amenorrha^a  :  1,  from 
absence  of  ovulation  ;  2,  from  absence  of  uterine  congestion  ;  3,  from  absence 
of  sanguineous  exhalation. 


262  UTERINE    DISEASES    IN    DETAIL 

Differential  diagnosis. — It  is  important  to  distinguish  idiopathic 
from  symptomatic  amenorrhoea,  from  retention  of  menseSj  and  from 
the  accidents  of  various  kinds  which  may  result  therefrom. 

Idiopathic  amenorrhoea  is  sometimes  well  tolerated  ;  but  generally  it 
produces  more  or  less  serious  local  or  general  phenomena.  Some- 
times the  local  symptoms  predominate,  especially  those  of  congestion ; 
fluxion  is  effected  but  has  not  its  natural  termination;  absence  of 
evacuation  is  not  compensated  by  the  natural  reaction  which  tends  to 
dissipate  the  fluxion  after  each  period,  and  the  congestion  continues  to 
increase,  sometimes  even  rising  to  the  degree  of  a  permanent  morbid 
condition.  Sometimes  fluxion  does  not  take  place,  but  this  absence 
causes  a  disturbance  in  the  general  circulation  and  in  all  the  other 
functions.  General  phenomena  are  manifested  :  in  a  few  women  it  would 
seem  that  the  habitual  absence  of  sanguineous  evacuation  produces  a 
plethora  (resulting  in  congestions  of  the  spleen,  liver,  lungs,  or  head, 
causing  in  the  last  case  headache,  drowsiness,  congestive  amaurosis,^ 
&c.) ;  in  others  on  the  contrary,  and  in  the  majority  the  blood 
becomes  impoverished,  innervation  is  disturbed,  and  symptoms  of 
chloro-ansemia  are  developed.  It  is  important  to  distinguish  chlorosis 
produced  by  amenorrhoea  from  that  of  which,  on  the  contrary,  amen- 
orrhoea is  symptomatic. 

Symptomatic  amenorrhoea  is  always  preceded  by  the  disease  of  which 
it  is  only  the  symptom,^  till  such  time  as  it  can  continue  of  itself,  by 
virtue  of  the  morbid  habit  which  the  repeated  suspension  of  menstrua- 
tion has  impressed  on  the  economy.  Amenorrhoea  symptomatic  of 
defective  development  may  have  a  number  of  features  in  common  with 
idiopathic  amenorrhoea  causing  them  to  be  confounded  together. 
Whether  there  is  absence  of  the  uterus  or  ovaries,  or  a  rudimentary 
condition  of  these  organs  [uterus  foetalis  or  infantilis)  they  have  the 
common  feature  of  amenorrhoea.  When  the  ovaries  are  wanting  there 
is  only  this  one  negative  symptom.  In  the  contrary  case,  we  gene- 
rally observe  all  the  prodromata  of  menstruation,  lumbar  or  hypo- 
gastric pain,  a  sense  of  pelvic  fulness  with  pain  radiating  down  the 
thighs.  After  lasting  for  some  days  this  ceases,  but  is  reproduced 
sooner  or  later  the  following  month  with  a  certain  regularity.  In 
other  cases  the  disturbance  is  less  marked  :  there  is  sometimes  palpita- 
tion of  the  heart  and  violent  headache  necessitating  bloodletting. 
Occasionally  phenomena  of  hsemorrhagiparous  congestion  are  devel- 
oped on  various  parts  of  the  body,  which  might  lead  us  to  think  that 
the  economy  was  in  need  of  depletion,  and  tried  to  effect  a  vicarious 
evacuation.  The  duration  of  these  troubles  and  hsemorrhagic  molimeu 
is  very  variable.  Sometimes  they  last  for  a  few  years  only,  not 
unfrequently,   however,   they   are   prolonged  for  twenty.      Then   a 

^  Such  is  the  case  related  by  Samelsohn  of  complete  amaurosis  the  result  of 
a  sudden  suppression  of  the  menses,  which  gradually  disappeared  when  men- 
struation was  again  established  seven  weeks  later  {Berlin.  Klin.  Wochenschr., 
18  Jan.,  1875). 

2  We  must  be  on  our  guard  against  the  tendency  that  women  have  o£  attri- 
buting  all  their  diseases  to  amenorrha3a  in  place  of  regarding  it  as  the  effect  of 
various  pathological  affections  from  which  they  may  be  suffering. 


AM£NORRH(EA  263 

gradual  amelioration  takes  place  similar  to  what   occurs   after   tlie 
menopause  in  women  who  have  suffered  from  obstinate  dysmenorrhoea. 

Menstrual  retention  may  be  diagnosed  by  the  hypogastric  tumour  of 
the  uterus,  disteoded  by  the  accumulation  of  blood.  The  symptoms 
experienced  by  patients  are  generally  in  proportion  to  the  quantity  of 
fluid.  Not  only  are  symptoms  of  molimen  manifested  every  month, 
but  there  are  signs  of  repletion  of  the  genital  organs  often  accom- 
panied by  fruitless  expulsive  eff'orts.  These  phenomena,  differing  as 
they  do  from  those  produced  in  the  majority  of  cases  of  amenorrhoea, 
are  attended  by  painful  periodical  exacerbations,  an  intolerable  and 
almost  continuous  nervous  erethism,  and  often  still  more  serious  symp- 
toms. In  short,  before  deciding  that  there  is  amenorrhoea,  we  must 
ascertain  that  the  genital  organs  are  in  normal  condition.  This 
examination  ought  not  to  be  neglected  even  in  women  who  have  had 
sexual  intercourse  or  children,  for  the  obstacle  to  the  discharge  of 
blood  is  often  internal  or  may  have  been  produced  after  labour.  The 
examination  should  not  be  confined  to  the  vulva  and  vagina,  but 
should  extend  to  the  uterus  and  its  appendages.  Lastly,  the  possi- 
bility of  pregnancy  must  not  be  lost  sight  of. 

Treatment. — The  indications  may  be  various.  In  the  first  place 
amenorrhoea  may  be  compatible  with  the  free  exercise  of  all  the  func- 
tions and  with  perfect  health,  in  which  case  there  is  evidently  no 
occasion  for  treatment.  It  is  the  same  when  it  is  irremediable  and 
symptomatic  of  an  incurable  disease  in  an  advanced  stage. 

Treatment  ought  to  be  confined  to  hygienic  measures  when  the 
amenorrhoea  is  only  a  delay  in  the  first  appearance  of  menstruation,  or 
the  result  of  convalescence  from  acute  disease  rather  than  amenorrhoea 
strictly  speaking,  and  should  be  directed  exclusively  to  the  affection 
which  has  suspended  ovulation  in  cases  of  symptomatic  amenorrhoea  ; 
consequently,  we  must  treat  nervous  asthenia,  haemorrhages,  im- 
poverishment of  blood,  anaemia,  chlorosis,  or  even  plethora  (when  it 
seems  to  have  a  share  in  producing  the  disease),  without  directing  our 
attention  to  the  genital  system,  and  only  endeavour  to  excite  the  ova- 
ries or  uterus  directly  by  more  or  less  powerful  stimulants  after  having 
cured  the  maladies  of  which  the  amenorrhoea  is  only  a  symptom. 

In  idiopathic  amenorrhcea  the  indications  vary  according  to  whether 
the  general  or  local  condition  predominates.  Almost  all  cases  may  be 
included  in  one  or  other  of  these  categories;  the  periodical  fluxion 
may  either  continue  to  take  place  in  the  uterus,  congesting  the  organ 
without  terminating  in  a  discharge  of  blood,  cases  of  this  category 
being  characterised  by  the  predominance  of  local  symptoms ;  or  the 
fluxion  may  not  even  take  place,  being  directed  instantaneously  after 
suppression  to  another  organ,  or  it  may  take  this  false  direction  at  a 
later  period,  or  not  at  all ;  cases  of  this  category  are  characterised 
by  the  predominance  of  general  phenomena.  The  one  class  or  the 
other,  according  to  the  case,  becomes  the  principal  source  of 
indication. 

The  local  phenomena  which  predominate  are  chiefly  congestive. 
"When  general  symptoms  predominate  they  are  more  varied.     For  the 


264  UTERINE    DISEASES    IN    DETAIL 

habitual  suppression  of  uterine  fluxion  and  evacuation  may  either  de- 
termine plethora  or  chloro-ansemia  with  their  various  aspects  and 
numerous  consequences,  or  fluxionary  movements,  so  varied  in  their 
progress,  tendency,  aim  and  termination.  Hence  two  kinds  of  indi- 
cations, the  one  being  dependent  on  the  defective  normal  fluxion  which 
has  to  be  recalled,  the  other  on  the  intensity  and  nature  of  the  general 
disorders  which  have  to  be  cured ;  the  one  class  may  predominate,  or 
they  may  do  so  alternately  at  different  periods  of  treatment  in  the  same 
patient. 

Indicatio7is  fiirnisJted  hy  local  troubles  or  hy  phenomena  of  uterine 
congestion, — It  is  not  enough  to  characterise  the  form  of  these  phe- 
nomena ;  in  order  to  treat  them  efficiently,  we  must  also  determine 
their  essential  cause  or  nature.  It  is  important  to  be  able  to  refer 
the  local  troubles  to  congestion;  but  this  persistent  congestion  is 
only  the  form  of  the  malady;  the  basis  of  the  morbid  state  which 
keeps  up  this  condition  is  a  disorder  aff'ecting  the  vitality  of  the 
uterus.  In  tracing  its  origin  to  this  source,  we  discover  that  the 
disorder  may  affect  the  vital  functions  of  the  organ,  its  sensibility, 
contractility,  secreting  power,  &c.,  or  the  properties  of  its  tissues, 
their  permeability,  elasticity,  resistance,  &c.  It  is  not,  however, 
always  possible  to  push  analysis  so  far  as  to  determine  with  certainty 
which  of  the  two  is  the  source  of  indication.  There  may  be  primarily 
or  secondarily  a  simultaneous  appearance  of  these  various  disorders 
of  vitahty,  which  we  regard  as  the  essential  cause  of  hindrance  in  the 
evolution  of  menstruation.  We  see  infinite  gradations  of  this  in 
practice,  but  in  this  description  we  can  only  touch  upon  the  principal 
varieties. 

Congestion  may  be  imperfect,  or  may  not  be  sustained  by  a  sufficient 
effort,  not  reaching  the  highest  expression  of  the  physiological  act 
capable  of  determining  evacuation.  In  this  case  we  must  strengthen 
the  fluxion  and  regulate  it,  stimulating  it  by  various  applications 
which  affect  the  vascular  system  of  the  uterus.  Gentle  purgatives, 
e.g.  castor  oil,  or  small  doses  of  aloes,  or  laxative  enemata  containing 
manna,  molasses^  honey,  or  a  mercurial  decoction,  or  one  of  lettuce 
and  white  beetroot,  to  which  may  be  added  a  few  spoonfuls  of  oil, 
glycerine,  or  a  little  soap,  produce  an  intestinal  flux^  which  is  favor- 
able to  the  estabhshment  of  menstruation.  On  the  other  hand,  mild 
attractives,  such  as  dry  cupping,  sinapisms  on  the  upper  and  inner 
parts  of  the  thighs  as  well  as  on  the  hypogastrium,  or  a  few  leeches 
appHed  to  the  external  surface  of  the  labia,  are  excellent  means  of 
inducing  an  external  discharge  of  the  blood  which  congests  the 
uterus. 

Uterine  congestion  may  be  sufficient,  the  means  of  expulsion  only  being 
defective.  Sometimes  irritability  of  the  organ  is  the  principal  obstacle. 
In  order  to  calm  this  we  must  have  recourse  to  emollients  in  various 
forms  :  general  baths,  sitz-baths,  liot  poultices  on  the  abdomen,  fumi- 
gations, enemata,  &c.  Sometimes  the  blood  is  retained  by  erethism  or 
by  spasm  of  the  uterus.  In  this  case  preparations  of  aconite,  henbanej 
belladonna,  or  poppy-heads  may  ^produce  the  desired  result ;  they  may 


AMENOERH(EA  265 

be  administered  interualljj  or  externally  in  the  form  of  enemata,  baths, 
fomentations,,  or  embrocations.  Sometimes  inertia  of  the  uterus  or 
suspension  of  its  muscular  contractility,  are  essential  conditions  of  the 
imperfection  of  the  act.  Emmenagogues  are  then  the  best  uterine 
evacuants,  especially  ergot ;  electricity,  and  douches  on  the  cervix  may 
also  be  tried  with  the  same  object. 

In  a  third  class  of  cases  congestion  is  more  than  sufficient,  exceeding 
the  limits  of  the  physiological  menstrual  state,  and  by  its  excess  hin- 
dering the  natural  discharge  from  taking  place.  The  uterus  is  turgid, 
its  volume  greatly  increased,  its  vessels  are  gorged,  its  fibres  distended, 
its  elasticity  and  contractility  diminished.  In  this  case  the  indication 
is  to  empty  the  vascular  system,  either  by  direct  depletion  or  by  revul- 
sion, with  the  object  of  subduing  the  excessive  fluxionary  movement 
which  is  the  primary  cause  of  this  congestive  tumefaction.  The 
best  of  all  revulsives  is  bloodletting  from  the  arm ;  it  ought  not  to 
be  copious,  especially  if  it  has  to  be  repeated ;  not  more  than  from 
three  to  six  ounces  of  blood  should  be  taken,  unless  the  intensity  of 
the  congestion  and  the  attendant  symptoms  require  a  more  copious 
evacuation.  This  is  sometimes  followed  by  an  immediate  appearance 
of  the  menses ;  or  it  allows  the  other  means  used  to  produce  their 
effect ;  or  it  may  only  produce  an  effect  on  the  following  periods,  at 
each  of  which  it  ought  to  be  repeated.  We  shall  have  occasion  to  see 
that  the  indication  for  bloodletting  occurs  in  other  circumstances, 
especially  in  the  treatment  of  amenorrhoea  symptomatic  of  uterine 
congestion,  metritis,  peri-uterine  inflammations,  &c. 

Indications  furnished  by  general  trouhles,  i.e.  by  the  absence  of 
uterine  fluxion  and  its  reaction  on  the  whole  economy. — The  aim  of 
some  is  to  attract  or  recall  fluxion  to  the  uterus,  that  of  others  to  cure 
the  general  disorders  or  various  affections  the  starting  point  of  which 
was  the  absence  or  suppression  of  menstruation, 

I.  To  attract  sanguineous  fliixion  to  the  uterus  or  recall  it  when  it 
has  ceased,  is  an  indication  which  M'e  cannot  always  fulfil,  nor  ought 
we  to  try  to  do  so  in  idiopathic  amenorrhoea  before  having  fulfilled  the 
second  of  the  two  indications  just  mentioned.  _For  the  general  dis- 
turbances imported  by  the  amenorrhoea  into  the  principal  functions  of 
women,  especially  when  they  have  reached  such  a  height  as  to  have 
become  themselves  morbid  affections,  may  ultimately  have  to  be 
regarded  as  the  essential  cause  of  the  suppression  of  menstruation. 
Idiopathic  amenorrhoea  touches  so  closely  upon  symptomatic  amenor- 
rhea at  this  point,  that  the  former  may  be  transformed  into  the 
latter ;  so  that  after  having  been  idiopathic  and  having  produced  dis- 
eases of  the  uterus  or  of  the  general  economy,  amenorrhoea  may  in  its 
turn  become  symptomatic  of  these  same  diseases.  Just  as  pain  is  the 
daughter  as  well  as  the  mother  of  inflammation,  amenorrhoea  is 
mother  and  daughter  successively  of  uterine  congestion  or  metritis,  of 
plethora,  anaemia,  chlorosis,  &c.  This  mutual  influence  is  exerted  in 
various  degrees,  and  the  nature  of  its  action  in  this  intervention  is  as 
variable.  But  whatever  its  mode  of  action  may  have  been,  the 
amenorrhoea  may,  in  its  turn,  become  so  dependent  on  certain  morbid 


266  UTERINE    DISEASES    IN    DETAIL 

conditions,  that  the  primary^  sometimes  the  only  indication,  is  to  treat 
these  diseases,  the  cure  of  which  will  bring  about  at  the  same  time, 
without  the  application  of  any  direct  means,  the  cure  of  the  amenor- 
rhoea.  We  must  therefore  take  this  subordination  into  account,  and, 
in  these  complex  cases,  know  how  to  fix  upon  the  dominant  indica- 
tion, because  it  is  the  primary,  sometimes  the  only  indication  to  be 
fulfilled. 

It  would  be  impossible  here  to  analyse  all  cases  of  this  kind,  or  to 
determine  when  one  of  these  indications  should  be  fulfilled  to  the 
exclusion  of  the  other,  when  one  before,  or  after  the  other,  or  when 
the  two  simultaneously.  Forced  to  separate  what  ought  often  to  be 
united,  and  to  describe  in  a  certain  order  of  succession  what  ought 
often  to  be  practised  in  an  inverse  order,  we  must  point  out  that  in 
describing  the  treatment  of  idiopathic  amenorrhoea,  we  have  given  not 
the  first  rank,  but  the  first  place  to  a  description  of  the  indications 
connected  with  defect  of  the  uterine  fluxion,  and  the  second  to  a 
description  of  those  connected  with  the  concomitant  general  disorders. 

To  determine  the  appearance  or  return  of  the  uterine  fluxion  is  an 
indication  that  can  be  fulfilled  by  means  analogous  to  those  employed 
to  attract  fluxion  to  any  part  of  the  economy.  It  is  manifestly  easier 
to  attract  to  the  uterus  and  to  establish  in  this  organ  a  fluxionary 
movement  which  is  natural  to  it,  than  to  attract  an  artificial  fluxionary 
movement  to  any  other  part  of  the  body,  the  latter  being  essentially 
a  morbid  act,  whilst  the  former  is  a  physiological  one.  This 
fluxionary  movement  being  intermittent  and  periodic,  the  means  used 
to  produce  it  ought  to  be  in  harmony  with  this  characteristic,  e.g. : 
when  we  have  not  succeeded  in  re-establishing  menstruation  during 
the  first  days  which  follow  a  sudden  suppression  of  the  period,  we 
must  limit  our  efforts  to  the  treatment  of  the  symptoms  produced, 
and  await  the  probable  return  of  the  following  period  to  try  new 
means. 

All  the  functions  of  the  uterus  having  a  share  in  the  maintenance 
of  its  physiological  state  will  have  an  equal  influence  in  the  cure  of 
amenorrhoea.  Menstruation  being  composed  of  several  successive 
acts,  we  shall  certainly  have  more  chance  of  restoring  the  first  of  these 
acts  to  its  normal  type  if  we  try  to  restore  the  others  consecutively, 
and.  to  bring  into  play  the  faculties  and  properties  of  the  organ  by 
means  of  which  they  are  carried  out.  For  instance,  evacuation  and 
congestion  will  encourage  the  physiological  return  of  fluxion.  The 
realisation  of  the  former  processes  will  exercise  a  kind  of  attraction  on 
the  latter  :  whilst  on  the  contrary  the  more  the  fluxion  falls  short  of  its 
final  result,  the  less  tendency  it  will  have  to  be  reproduced.  These 
principles  ought  to  guide  the  practitioner  as  to  the  nature  of  the. 
means  he  should  use,  and  the  order  in  which  he  should  employ  them. 
Of  all  these  means  the  most  physiological  is  marriage;  we  are  there- 
fore justified  in  advising  it,  when  amenorrhoea  does  not  seem  to  be 
dependent  on  any  malformation  or  defective  sexual  development,  nor 
to  have  determined  the  appearance  of  any  serious  disturbance  in  the 
uterine  system  or  in  the  general  condition  of  the  patient.     Before 


AMENOREHCEA  267 

giving  such  advicCj  however,  we  must  ascertain  that  a  uterus  is 
present  and  that  there  is  no  obstacle  to  the  discharge  of  the  menses. 
If  this  is  the  case^  or  if  amenorrhoea  has  occurred  after  repeated  men- 
struation, we  must  resort  to  those  general  and  local  means  which  have 
a  tendency  to  encourage  uterine  fluxion  and  hsemorrhage.  All  medi- 
caments which  attract  the  blood  to  the  lower  part  of  the  body,  to  the 
pelvisj  rectum  and  uterus  are  used  to  fulfil  this  indication  in  the 
treatment  of  amenorrhoea.  Women  themselves  know  the  utility  of 
foot-baths,  sitz-baths,  sinapisms,  fumigations,  leeching  and  purgatives 
in  determining  the  appearance  of  the  catamenia  or  recalling  them 
when  suppressed.  They  often  employ  them  without  consulting  a 
physician  in  cases  of  sudden  suppression  of  the  menses  under  the 
mfluence  of  moral  emotion,  a  chill,  arrested  perspiration,  &c.  Very 
hot  sitz-baths  repeated  several  times  a  day,  especially  when  mustard  is 
added  (the  effect  of  which  is  more  durable  than  that  of  heat)  ;  fumiga- 
tions taken  by  sitting  on  a  high  vessel  at  the  bottom  of  which  boiling 
water  has  been  poured  over  a  handful  of  aromatic  herbs ;  vapour 
douches  round  the  pelvis ;  prolonged  tepid  foot-baths  with  the  addi- 
tion of  half  a  pound  of  mustard;  sinapisms  applied  to  the  lower  part 
of  the  body,  especially  to  the  inner  side  of  the  thighs  and  to  the  hypo- 
gastrium ;  dry  cupping  apphed  to  the  same  parts  ;  the  application  of 
leeches  to  the  groins,  anus,  external  surface  of  the  labia  or  even  to 
the  cervix  (care  being  taken  in  the  latter  case  to  apply  not  more  than 
two  on  each  side,  and  to  repeat  this  application  two  or  three  days 
running);  drastic  purgatives,  such  as  jalap,  gamboge  or  aloes;  enemata 
of  aloes  containing  from  5ss  to  5iiss  of  aloes  suspended  in  the  yolk  of 
an  egg  and  ^iij  of  water  (Schoniein) ;  sometimes  cold  douches  to  the 
pelvis  and  legs ;  such  are  the  means  usually  employed.  They  often 
suffice  when  repeated  for  several  months  consecutively.  When  neces- 
sary a  stimulus  may  be  applied  directly  to  the  vagina  and  cervix  by 
irritating  vaginal  injections.  Ashwell  advises  10  to  60  minims  of 
liquid  ammonia  mixed  with  ^iss  of  milk  repeated  several  times  a  day  ; 
beginning  with  ten  drops  and  adding  five  every  day  till  a  slight  leucor- 
rhoea  is  produced. 

There  are  various  ways  of  encouT&gmg persistence  of  the  congestion 
which  these  fluxionary  movements  determine  in  the  uterus ;  for 
instance  by  applying  very  hot  emollient  cataplasms  for  a  long  time 
to  the  abdomen,  or  by  enveloping  the  pelvis  and  abdomen  with  hot 
flannels  impregnated  with  aromatic  vapours,  and  covered  with  oil-silk 
or  gutta  percha,  so  as  to  maintain  a  constant  moist  heat.  For 
chlorotic  patients  Pajot  recommends  that  the  lower  limbs  should  be 
bandaged,  a  powerful  and  rational  means  when  blood-letting  is  contra- 
indicated,  and  when  the  digestive  organs  do  not  tolerate  medicines. 

Other  medicaments  seem  to  possess  the  property  not  only  of  con- 
gesting but  also  of  evacuating  the  uterus  by  causing  contraction  of 
its  muscular  wall.  Their  real  or  supposed  action  on  the  uterus  has 
gained  for  them  the  name  of  emmenagogues.  I  do  not  refer  to  the 
tincture  of  iodine  and  some  other  medicines  which  have  been  tried 
and  too  highly  vaunted  by  certain  physicians ;  probably  they  answer 


2()8  tJTEEINE    DISEASES   IN   DETAIL 

special  indications  and  modify  tlie  general  health  rather  than  exercise 
any  direct  local  action.  But  amongst  emmenagogues  proper  if  the 
action  of  ergot  is  incontestable,  what  are  we  to  think  of  rue,  savin, 
absinthe,  saffron,  &c.,  which  enjoy  a  popular  reputation  ?  Ergot 
evidently  causes  uterine  contractions  and  facilitates  the  menstrual  dis- 
charge. It  is  generally  associated  with  the  others  in  various  popular 
recipes  of  doubtful  efficacy.  The  following  pills  combined  with  the 
other  means  just  enumerated  often  prove  useful : — Il2ie,  Savin, 
Mrgot.  aa  gr.  |,  Aloes  gr.  \  to  gr.  |. — Make  one  pill  and  take  3  pills 
the  first  day,  6  the  second,  9  the  third,  three  times  a  day.  As  a  rule 
these  pills  should  be  preceded  by  foot-baths,  sitz-baths  and  fumiga- 
tions, and  leeches  should  be  applied  to  the  labia  the  three  days  on 
which  the  pills  are  taken.  These  pills  often  cause  colics  and  a  little 
diarrhoea.  Joret^  and  Marotte"  give  apiol  (the  active  principle  of 
apium  petroselimim)  for  amenorrhcea  and  dysmenorrhcea  in  4-grain 
doses  twice  a  day  at  the  time  of  the  monthly  period.  Marotte  says 
that  this  remedy  is  sometimes  very  efficacious,  especially  in  cases  of 
simple  amenorrhcea,  when  apparently  the  only  indication  is  to  act  on 
the  uterine  circulation,  on  its  vaso-motor  system,  and  so  to  induce 
an  escape  of  blood  from  the  vessels.  It  is  the  same  in  dysmenorrhoea 
not  dependent  on  any  mechanical  obstacle  or  organic  condition  of  the 
uterus.  If  amenorrhcea  and  dysmenorrhoea  are  partly  dependent  on 
a  general  local  condition,  apiol  can  only  be  of  use  when  the  comjjlex 
condition  has  been  brought  back  to  that  of  simple  amenorrhcea  or 
dysmenorrhoea.  The  use  of  electricity  is  quite  rational,  and  has  given 
incontestable  proofs  of  its  efficacy.  One  of  the  poles  should  be  ap- 
plied to  the  loins,  the  other  to  the  groins,  hypogastrium,  and 
perineum.  The  cervix  may  be  seized  with  an  exciter  having  two 
branches  isolated,  so  as  to  protect  the  vagina,  except  at  the  extremities 
which  embrace  the  cervix ;  or  one  of  the  poles  may  be  applied  to  the 
cervix,  the  other  to  the  hypogastrium ;  or  one  of  the  poles  to  the 
uterine  cavity,  the  other  to  the  cervix,  hypogastrium,  or  rectum.  It 
is  easy  to  understand  how  this  repeated  excitation  may  stimulate 
the  fluxionary  movement  and  cause  contraction  of  the  uterus.  The 
cold  douche  applied  to  the  cervix  has  an  analogous  action,  and  may  also 
be  useful;^  metritis,  however,  is  to  be  dreaded.  Simpson  used  other 
very  ingenious  means,  based  on  the  knowledge  of  the  physiological 
laws  of  the  uterus,  and  producing  the  effect  of  exciting  contractions 
in  that  organ.  For  simple  dilatation  of  the  os  externum,  as  in  the 
case  of  mechanical  dysmenorrhoea,  Simpson  used  stems,  or  rather 
pessaries  {See  Tigs.  185  and  186),  the  stems  of  which  varied  in 
diameter,  like  the  bougies  with  which  the  urethral  canal  is  dilated. 
But  besides  these  pessaries,  the  mechanical  action  of  which,  although 
limited  to  the  orifices,  causes  uterine  contractions  by  the  contractile 
reaction  of  the  body  from  titillation  of  the  cervix,  Simpson  sometimes 
introduced  into  the  uterus  longer  stem  pessaries  made  of  two  metals^ 

1  Bulletin  general  de  thh'apeuUque,  f  ev.,  1860. 

2  Id.,  octobre,  1863. 

3  Panas.     These  de  Enguehard.     Paris,  1868. 


AMENORRHCEA  269 

an  instrument  which  we  have  already  described  as  the  galvanic  stem 
pessary.  At  other  times  he  applied  what  he  called  a  dry  cupping-glass 
{See  Fig.  207)  to  the  uterine  cavity,  i.  e.  a  hollow  sound  pierced  with 
holes  at  its  terminal  extremity,  the  other  end  being  screwed  on  to  a 
small  aspirator.  As  a  vacuum  is  made  in  the  instrument,  a  kind  of 
aspiration  is  effected  on  the  mucous  membrane  of  the  uterus,  which 
is  thereby  sucked  against  the  minute  apertures  of  the  sound  through 
which  eventually  the  blood  filters  after  repeated  applications 
have  been  made  several  days  consecutively,  or  at  several  monthly 
periods. 

II. —  General  disorders  due  to  amenorrhcea  are  very  numerous  and 
very  varied.  They  may  be  ranged  under  two  principal  divisions, 
according  as  they  depend  on  anaemia  or  plethora.  There  may  be 
a  general  'pl^tliora,  or  too  great  a  quantity  of  blood  in  proportion 
to  the  size  of  the  vessels  which  contain  it ;  the  indication  then  is 
clear;  we  must  empty  the  vascular  system  by  repeated  blood-letting, 
general  and  local,  by  purgatives,  by  regimen,  by  diminishing  the 
quantity  of  food,  by  exercise,  &c.  The  state  of  plethora  may,  so  to 
speak,  be  localised  on  one  point  or  one  organ,  which  has  become  con- 
gested owing  to  the  repeated  fluxions  of  which  it  has  been  the 
seat  since  the  commencement  of  the  amenorrhcea.  This  congestion 
is  permanent  or  temporary  ;  it  may  be  intermittent,  recalling  the 
menstrual  periodicity,  as  I  shall  explain  in  speaking  of  deviated  or 
supplementary  menstruation.  It  may  even  extend  to  hsemorrhage. 
Hence  different  indications  varying  with  the  seat  of  congestion,  its 
character,  intensity,  duration,  its  intermittence,  its  sequences,  such 
as  hsemorrhage,  &c.  If  the  head,  chest,  or  other  important  organ  is 
the  seat  of  the  evil,  the  latter  must  be  treated  with  greater  energy 
without  reference  to  the  uterine  fluxion  which  can  be  recalled  after- 
wards. In  short,  we  must  carefully  watch  the  affected  organ  in  the 
interval  or  in  the  absence  of  the  menses,  and  try  to  destroy  the  morbid 
predisposition  which  makes  it  the  locus  minoris  resistentice  (E.  Fritz). 
Usually,  however,  the  general  disorders  of  health  assume  an  opposite 
character  from  that  of  plethora,  that  namely  of  anamia  or  chlorosis. 
These  two  maladies  are  often  confirmed  and  greatly  increased  by 
amenorrhcea.  The  nervous  disorders  which  follow  suspension  of 
menstruation,  even  when  they  do  not  assume  the  character  of  true 
neurosis,  greatly  contribute,  in  concert  with  digestive  troubles  and 
dyspepsia,  to  derange  nutrition,  and  consequently  to  throw  patients 
into  an  anaemic  condition  or  to  develop  a  tendency  to  chlorosis.  This 
disease  is  apt  to  produce  derangements  in  the  health  very  difficult  to 
remedy.  Lastly,  under  these  combined  influences  we  may  see  diathetic 
affections  developed  in  patients  having  a  predisposition  to  them,  but  in 
whom  the  outbreak  is  occasioned  by  the  general  debility  of  the 
constitution. 

Such  are  the  various  sources  of  indications  arising  most  frequently 
from  general  disorders  of  the  health  accompanying  amenorrhcea.  The 
indications  are  the  same  when  these  diseases  have  preceded  and  pro- 
duced amenorrhcea  in  place  of  following  it.     In  both  cases  we  must  first 


270  UTEEINE    DISEASES  IN    DETAIL 

of  all  direct  our  attention  to  the  affection  in  question,  and  when  it 
is  cured  the  amenorrhoea  will  disappear  spontaneously. 

In  addition  to  the  means  to  be  used  in  the  treatment  of  a  nervous 
condition,  to  those  which  are  ef&cacious  in  cases  of  dyspepsia,  and  to 
the  medicaments  peculiarly  suitable  to  the  diathetic  affection  that  may 
have  been  developed,  we  must  employ  tonics  of  all  kinds. 

Hygiene  must  be  the  basis  of  our  treatment ;  a  country  life,  exer- 
cise, gymnastics,  hydropathy,  warm  clothing,  nourishing  and  easily- 
digested  food,  tonics,  and  iron  in  one  of  the  forms  already  indicated, 
will  generally  be  successful.  The  use  of  natural  effervescing  and  chaly- 
beate waters,  taken  on  the  spot,  and  so  involving  change  of  scene  and 
chmate,  is  often  of  great  service.  The  waters  of  Lamalou,  Andabre, 
Sylvanes,  Boulou,  Vals,  (Ardeche),  Eoyat,  Vichy,  may  be  prescribed 
in  such  cases  with  great  hope  of  success. 

Retention  of  the  Menses. 

This  condition  is  characterised  by  the  apparent  absence  of  the 
catamenia,  which,  owing  to  some  cause  or  other,  are  retained  in  the 
vagina  or  uterus.  It  is  not,  therefore,  strictly  speaking,  a  disease ;  at 
the  same  time  it  is  so  marked  a  symptom  and  connected  so  closely 
with  certain  anatomical  lesions,  that  it  is  convenient  to  describe  these 
various  lesions  under  this  common  name.  Amongst  the  maladies 
which  may  be  the  causes  of  this  accident  the  most  important  are : 

1.  Congenital  imperforation  of  the  vulvo-uterine  canal,  including 
the  non-separation  of  the  external  genital  organs,  imperforation  of 
the  hymen,  absence  or  obliteration  of  the  vagina,  imperforation  of  the 
cervix. 

2.  The  accidental  obliteration  of  the  uterus  or  vagina  owing  to 
cicatrix  or  to  gangrene. 

In  neither  of  these  two  cases  can  the  normal  menstrual  discharge 
take  place  by  the  efforts  of  nature.  Excretion  by  abnormal  paths 
{e.  g.  genito-rectal  or  tubo-vaginal)  can  only  be  effected  with  great 
danger. 

Retention  of  the  menses  as  a  morbid  condition,  therefore,  is  limited 
to  symptoms  pathognomonic  of  atresia  of  the  genital  canals,  i.  e.  to 
cases  in  which  some  obstacle,  congenital  or  acquired,  prevents  the  dis- 
charge of  the  catamenia.  Characteristic  troubles  follow,  and  the  indica- 
tion evidently  is  to  allow  the  escape  of  the  fluid  accumulated  in  the 
cavity  above  the  obstacle. 

Puech^  has  collected  and  scientifically  explained  all  cases  of  this  kind 
in  a  monograph  printed  in  1863,  in  the  Transactions  of  the  Academy 
of  Science  and  Letters  of  Montpellier,  from  which  I  shall  make 
numerous  quotations. 

The  atresia  (literally  absence  of  orifice)  or  anatomical  locaHsation 
of  the  obstacle  varies  in  its  seat  and  origin. 

I.  With  regard  to  the  seat  of  the  atresia,  three  kinds  may  be  dis- 
tinguished depending  on  whether  it  is  in  the  vulva,  vagina,  or  uterus. 

^  Be  I'atresie  des  voies  genitaJes  de  lafemme,  in-4°,  p.  165.     Paris,  1864. 


RETENTION   OF  THE    MENSES  271 

1.  Vulval  atresia. — The  labia  majora  as  well  as  the  minora  may 
contract  adhesions.  These  are  almost  always  cicatricial;  they  never 
cause  retention  of  the  menses,  but  they  may  interfere  with  the  expul- 
sion of  the  urine  or  lead  us  to  suspect  the  existence  of  stone,  and  they 
necessitate  an  operation,  insignificant  as  a  rule.  With  the  exception 
of  cicatricial  adhesions  they  yield  to  simple  traction.  Imperforation 
of  the  hymen  is  the  most  common  form  of  vulval  atresia.^  Puech  has 
quoted  151  cases.  Atresia  of  the  hymen,  which  is  most  frequently 
congenital,  may  be  complicated  by  an  obstacle  in  the  vagina,  as 
Euysch,  Schultz,  Walther  and  Burns  have  observed,  or  by  an  obstacle 
in  the  cervix,  as  seen  by  Butler  and  Picard. 

2.  Vaginal  atresia  may  be  congenital  or  acquired.  Congenital 
vaginal  atresia  is  said  to  be  simple  when  the  obstacle  is  limited  to  the 
vagina,  complicated  when  it  involves  both  vagina  and  cervix,  com- 
plex when,  the  vagina  being  double,  one  of  the  canals  is  obstructed. 
The  first  kind  is  the  most  common.  It  may  be  subdivided  according 
to  the  extent  of  the  obstacle  into  three  varieties.  In  the  first  are  in- 
cluded membranous  imperforations  ;  in  the  second,  cases  in  which  the 
obstacle  extends  from  10  to  40  millimetres;  whilst  the  third  includes 
those  exceeding  the  last  limit.  The  second  kind  is  distinguished  from 
the  preceding  one  by  imperforation  of  the  cervix ;  it  presents  two 
varieties,  according  as  the  two  obstacles  are  or  are  not  separated  by  a 
cavity.  The  third  kind  is  characterised  by  duplicity  of  the  vagina  and 
imperforation  of  one  of  the  canals.  This  kind,  the  rarest  of  all,  has 
been  observed  by  Leroy,^  Deces^  and  Eokitansky.*  Fifty-three  cases 
are  recorded  of  acquired  vaginal  atresia.  They  may  be  complicated  by 
-multiple  adhesions  or  by  a  vesico-vaginal  fistula,  as  seen  by  Meerck 
and  Puech. 

3.  Although  uterine  atresia  is  rarest  of  all,  fifty-four  cases  have 
been  collected  by  Puech.  It  may  be  congenital  or  acquired.  In 
the  first  case,  there  is  imperforation  of  the  cervix;  in  the  second, 
obliteration.  Imperforations  are  said  to  be  simple  when  there  is  only 
one  cervix ;  complex  when,  the  uterus  being  double,  one  of  the  canals 
is  occluded.  There  are  on  record  thirty-four  cases  of  the  first  kind 
and  only  two  of  the  second.  The  seat  of  obliteration  is  generally  the 
lower  part  of  the  cervix,  and  to  this  there  is  but  one  exception  out  of 
twenty-one  cases,  and  that  is  recorded  by  Mattei,  who  observed 
obliteration  of  the  os  internum. 

II.  With  regard  to  the  origin  of  atresia,  cases  may  be  divided  into 
congenital  and  acquired.  Congenital  atresia  is  an  imperforation, 
acquired  atresia  an  obliteration. 

1.  Imperforation,  which  occurs  most  frequently,  is  owing  to  arrested 
development.     Taking  the  three  zones  (vulva,  vagina,  uterus)  into 

'  We  find  a  case  of  this  kind  in  the  Ejihcmcrides  d'Alleviagne,  Dec.  2,  .3rd 
year,  Obs.  151,  quoted  by  Quesnay  in  his  Memoire  sur  les  vices  cles  humeurs 
{Memoires  de  I'Acad.  ray.  de  Chirurgie,  t.  i).  See  a  case  of  atresia  of  the 
hymen,  Fig.  97,  p.  90. 

*  Journal  des  connaissances  vuklicales,  1S31. 
^  Bulletin  de  la  Soch'di  anatoviique,  1851. 

*  Zeitsclwift  der  Gesellschaft  der  A«rzte,  18G(). 


272  UTERINE    DISEASES   IN   DETAIL 

which  the  genital  economy  may  be  divided  with  regard  to  develop- 
ment, we  find  the  central  zone  th.e  seat  of  the  abnormality  in  197  out 
of  230  cases;  the  central  zone  and  the  internal  zone  affected  simul- 
taneously in  7  cases;  and  in  31  the  internal  one  alone  affected. 
These  malformations  when  cured  are  not  inherited ;  at  least  we  have 
no  examples  of  this  kind. 


Fig.  211. Congenital  atresia  of  tlie  vagina,  from  a  preparation  in  St.  George's 

'  Musenm  (from  Barnes)  :  r,  dilated  uterus  ;  v,  vagina  dilated  above  the 
seat  of  imperforation,  through  which  a  sound  (b)  has  been  passed. 

2.  Olliterations  are  due  to  various  causes,  the  most  frequent  being 
long  and  difficult  labours,  and  especially  laceration,  suppuration,  and 
ganorene ;  eleven  cases  are  recorded  of  their  occurrence  in  the  cervix 
and°thirty-eight  in  the  vagina.  Tour  times  they  occurred  after  the  use  of 
caustics  which  in  one  case  only  had  been  resorted  to  for  a  criminal 
purpose,  in  the  others  they  had  been  employed  as  therapeutic 
means.  '  The  cases  recorded  by  "Williams  and  Eigby,  in  which  caustics 
had  been  used  to  cure  cervical  ulcers,  ought  to  be  a  caution  to  sur- 
geons. I  myself  have  had  to  remedy  11  cases  of  constriction  and  9  of 
complete  obliteration  either  of  the  os  internum  or  of  the  upper  part 
of  the  vagina  behind  which  the  cervix  was  imprisoned,  owing  to 
the  inopportune  or  exaggerated  application  of  caustics  to  the  upper 
part  of  the  vagina  or  to  the  cervix.  At  other  times  this  accident  is 
caused  by  acute  or  chronic  inflammation  of  the  cervix  or  vagina; 
sometimes  it  is  of  spontaneous  or  unknown  origin,  sometimes  it  is 


EETENTIOX    OF    THE    MENSES 


273 


produced  by  excessive  coitus^  by  irritating  manipulations,  by  a  tumour 
or  tiexion  of  the  uterus.  Syphilis,  diphtheria,  scarlatina,  measles  and 
smallpox  are  also  occasional  causes.  Lastly,  cholera  (three  cases)  and 
typhoid  fever  (four  cases),  by  producing  mortification  of  the  mucous 
membrane  of  the  vagina  or  cervix,  have  brought  about  the  same  result. 
In  short,  the  morbid  adhesions  which  cause  obliteration  of  the  genital 
canals  depend  on  the  formation  of  cicatricial  tissue  which  unites  the 
two  ulcerated  surfaces.     Happily  for  the  patients  these    adhesions 


Fig.  212. — Acquired  atresia  (obliteration)  of  the  cervix,  from  a  preparation 
given  by  Barnes  to  the  London  Hospital.  A  woman  of  forty-three, 
married  and  sterile.  Obliterating  adhesions,  caused  by  endometritis  in  a 
and  h' ;  c,  lower  part  of  the  cer\ax  ;  h,  middle  part  dilated  ;  a,  cavity  of 
the  body  dilated  as  well  as  the  Fallopian  tubes. 

produce  contraction  and  mechanical  dysmenorrhcea  oftener  than 
obliteration. 

Diagnosis. — Atresia  of  the  genital  canals,  whatever  may  be  its  seat 
(whether  vulva,  vagina  or  uterus),  may  be  simple,  complicated  or 
complex. 

The  retention  of  the  secretion,  which  is  total  and  forms  a  unilocular 
or  bilocular  tumour  in  the  two  first  cases,  is  only  partial  in  the  third, 
giving  rise  to  the  singular  phenomenon  of  the  free  discharge  of  the 
menses,  together  with  all  the  symptoms  of  mechanical  dysmenorrhcea 
and  of  menstrual  retention,  including  the   tumour   caused    by    the 

18 


274  UTERINE   DISEASES    IN    DETAIL 

retentum,  with  this  difference,  that  in  place  of  being  median   this 
tumour  is  lateral  or  unilateral. 

Subjective  slffns.—The  dominant  symptom  of  atresia  therefore  is 
retention  of  the  menses  accompanied  by  phenomena  of  various  kinds ; 
some  local,  either  uterine  (including  hsemorrhage)  or  in  neighbouring 
organs  ;  others  general^  symptomatic  or  sympathetic.     In  congenital 
atresia  the  commencement  is  often  unnoticed  ;  it  is  mistaken  for  diffi- 
culties attending  the  advent  of  menstruation,  the  symptoms  subside  in 
the  interval  of  the  fluxionary  movements,  and  the  uterus  gradually 
distends.     Acquired  atresia,  also,  may  be  well  tolerated  at  first ;  even 
from  the  beginning,  however,  the  symptoms  are  more  serious  than  in 
the  former.     In  both  cases  they  take  the  following  course :  at  the  time 
of  the  monthly  periods  the  patients  experience  a  sense  of  discomfort 
and  weight  in  the  pelvis.     The  back  feels  as  if  it  were  broken,  and 
afterwards  becomes  the  seat  of  pains  which  originate  in  the  loins  and 
extend   to  the  hypogastrium   and   anus.     These  colics,  after  having 
lasted  from  three  to  six  days,  cease  of  themselves.     At  the  next  period 
the   same  phenomena    take    place ;    only  they  gradually  increase  in 
intensity,  the  renal  or  lumbar  pains  become  more  frequent  and  more 
acute,  their  morbid  character  increases,  and  sooner  or  later  expulsive 
pains  are  developed  similar  to  uterine  contractions  at  labour.     At  the 
same  time  other  hypogastric  symptoms  show  themselves;  the  formation 
of  a  tumour  of  gradually  increasing  size,  due  to  the  dilatation  of  the 
uterine  cavity  from  the  accumulation  of  blood,  is  the  inevitable  con- 
sequence of  retention  of  the  menses  and  leads  to  various  complications. 
These  are  generally  in  proportion  to  the  quantity  of  fluid  contained  in 
the  womb.     If  the  uterine  tumour  presses  on  the  sacro-lumbar  nerves 
it  causes  a  tingling  and  numbness  in  the  legs.     If  it  compresses  the 
rectum  it  produces  constipation  or   tenesmus ;    whilst    if  it  pushes 
against  the  bladder  it  sets  up  not  only  vesical  tenesmus  and  dysuria, 
but  also  retention  or  incontinence  of  urine. 

For  some  months  these  are  the  only  disturbances  observed.  The 
stomach  and  nervous  system,  however,  are  soon  ■  affected  sympatheti- 
cally. There  is  loss  of  appetite,  nausea  and  even  vomiting.  The 
reaction  on  the  nervous  system  is  quite  as  serious,  a  state  of  erethism 
is  produced  by  the  intolerable  pains  which  continue  almost  without 
intermission,  as  well  as  a  feeling  of  suffocation  and  attacks  of  dyspnoea. 
Sometimes  even  delirium  occurs,  with  more  or  less  violent  fits  of 
convulsion ;  there  is  often  loss  of  self  control  verging  on  insanity ;  a 
propensity  to  suicide  may  even  manifest  itself.  The  interval  of  relief 
between  each  monthly  period  gradually  becomes  shorter.  The  crises 
follow  almost  uninterruptedly,  the  general  health  suffers  seriously,  life 
being  a  long  series  of  continued  sufferings  to  the  patient  mingled  with 
periodical  exacerbations. 

Objective  signs. — The  symptoms  revealed  by  examination  of  the 
parts  vary  according  to  the  seat  and  existence  of  the  obstacle. 

I.  In  imperforation  of  the  hymen  the  touch  and  sight  discover,  at 
the  entrance  of  the  vulva,  a  tumour  sometimes  deep  red  sometimes 
violet,  varying  in  size  between  a  chestnut  and  a  large  apple.     When 


RETENTION    OP    THE    MENSES  275 

the  hymen  is  very  much  distended  the  nymphse  may  be  effaced.  This 
tumour,  which  is  generally  insensible,  becomes  distended  and  painful 
at  the  monthly  period.  Efforts  of  any  kind,  cough  or  pressure  on 
the  hypogastrium,  by  making  it  more  prominent,  allow  jfluctuation  to 
be  perceived.  The  conical  form  of  the  tumour,  its  projection  between 
the  labia,  its  spontaneous  reduction,  have  led  to  its  being  mistaken  for 
prolapsus  uteri.  Dubois  de  le  Boe,  Mauriceau,  Amand,  have  related 
cases  of  this  mistake.  In  other  cases  it  has  been  said  to  resemble  the 
bag  of  waters,  and  this  singular  error  of  diagnosis  vias  once  made. 

II.  In  atresia  of  the  vagina,  when  the  imperforation  is  membranous, 
the  results  arrived  at  by  touch  are  identical  with  those  just  enumerated. 
When  the  obstacle  is  more  extensive  rectal  touch  must  also  be 
employed.  To  measure  the  length  of  this  obstacle  the  thumb  is  intro- 
duced into  the  lower  part  of  the  vagina  till  the  occlusion  is  reached,  whilst 
the  index  finger  of  the  same  hand  is  passed  into  the  rectum  till  the  lower 
border  of  the  tumour  is  reached.  The  space  between  the  finger  and 
thumb  gives  an  idea  of  the  extent  of  the  obstacle  ;  if  the  thumb  is  not 
sufficient  the  index  of  the  other  hand  is  substituted  for  it,  or  a  metallic 
sound  :  the  results  of  this  mode  of  exploration,  though  less  exact,  are 
valuable.  Lastly,  to  estimate  the  thickness  of  the  tissues  separating 
the  bladder  from  the  rectum,  a  sound  is  introduced  into  the  bladder, 
and  is  moved  about  whilst  the  index  finger  placed  in  the  rectum  follows 
its  course ;  we  can  judge  of  the  space  which  separates  the  sound  from 
the  finger,  and  consequently  of  the  thickness  of  the  tumour,  by  the 
facility  and  clearness  with  which  the  contact  of  the  instrument  is  per- 
ceived. It  is  curious  that,  in  some  cases  of  obliteration  of  the  vulva 
and  vagina  or  of  partial  or  total  absence  of  the  latter,  communications 
have  sometimes  existed  under  the  form  of  a  fistula  between  the  uterus 
and  the  rectum  or  the  bladder  or  urethra,  these  canals  serving  for 
coitus  to  the  extent  of  permitting  conception  to  take  place.  Oldham, 
Ilouth,^  Uterhart^  and  Spencer  Wells  ^  have  met  with  cases  where  the 
urethra,  being  either  originally  large  or  dilated  by  use^  has  served  for 
coitus,  and  sometimes  even  for  menstruation. 

III.  In  atresia  of  the  cervix,  vaginal  touch  reveals  the  cervix 
shortened  and  deformed,  projecting  very  slightly  into  the  vagina  and 
presenting  no  orifice  whatever.  The  speculum  confirms  these 
data  and  allows  the  colour  of  the  parts  to  be  seen.  The  most  signi- 
ficant characteristic,  however,  is  that  produced  by  distension  of  the 
uterus,  by  the  tumour  so  formed,  and  its  projection  at  the  hypo- 
gastrium. 

Hypogastric  tumour. — The  hypogastric  tumour,  more  or  less  volu- 
minous according  to  the  frequency  of  menstruation  and  the  quantity 
of  blood  exuded,  is  formed  by  the  distended  uterus.  Bounded  below 
by  the  obstacle,  on  each  side  by  the  bones  of  the  pelvis,  it  can  only 
be  developed  upwards.  Consequently,  although  at  first  contained  in 
the  pelvis,  it  soon  extends  beyond  it,  and  rising  into  the  abdominal 

1  Obstetrical  Trans.  1870. 

2  Berlin.  Klin.  Wochenschrift,  18()9. 

3  Med.  Times  and  Gazette,  1870. 


276 


UTERINE    DISEASES    IN    DETAIL 


cavity  increases  in  size  till  it  reaches  the  dimensions  of  a  pregnancy  at 
full  term,  sometimes,  though  rarely,  exceeding  even  that.^  The  tumour 
progresses  by  degrees,  increasing  and  rising  at  the  menstrual  periods, 
diminishing  and  falling  in  the  intervals,  but  each  time  remaining 
larger  than  it  was  before.  Its  form  is  generally  globular,  at  other 
times  it  is  ovoid  and  subdivided  by  strangulation,  like  a  pilgrim^s 
gourd,  when  the  atresia,  being  at  the  base  of  the  vagina,  has  suc- 
cessively determined  distension  of  the  vagina,  cervix,  and  uterus,  the 
situation  of  the  sphincters  of  the  vaginal  orifice  and  isthmus  being 
indicated  by  the  resistance  they  offer  to  dilatation,  preventing  the 


Fig.  213. — Globular  hypogastric  tumour,  with  lateral  appendages,  produced  by 
dilatation  and  hypertrophy  of  the  womb  M  and  of  the  Fallopian  tubes 
T  T,  owing  to  retention  of  the  menses  from  complete  absence  of  the  vagina 
V.  Retention  of  the  menses  for  seven  years,  puncture  by  the  rectum, 
followed  by  purulent  peritonitis  causing  death  on  the  eighth  day  (after 
Fiirst,  of  Leipsic). 

tumour  from  acquiring  at  these  points  the  dimensions  which  it  attains 
in  the  vagina  and  in  the  cervical  and  uterine  cavities.  Its  position 
is  generally  median,  but  it  may  be  more  or  less  inclined  and  even 
lateral. 

As  a  rule  this  tumour  is  single,  but  in  some  cases  it  is  double  and 
even  triple.  These  two  or  three  tumours  depend  either  on  division 
of  the  uterus  (Leroy,  Deces,  Eokitansky,  Nelaton)  or  on  dilata- 
tion of  the  Pallopian  tubes  by  menstrual  blood.  In  the  latter  case, 
which  is  important  in  reference  to  the  prognosis,  the  principal  tumour 
is  bounded  on  one  or  both  sides  by  an  ovoid,  cylindrical  or  vermiform 
swelling,  soft  and  rolling  under  the  finger. 

This  tumour  is  resistant  or  doughy  to  the  touch,  communicating 
a  sensation  of  fluctuation ;  but  the  counter-stroke  produced  by  the 

'  Tumours  formed  by  the  retention  and  accumulation  of  fluids  in  the  imper- 
forate uterus  or  vagina  may  acquire  so  great  a  size  in  the  fojtus  as  to  form  an 
obstacle  to  parturition.  (Dr  Gervis  and  Dr  Gomer  Davies,  quoted  by  Alph. 
Hergott,  Des  maladies  fcetales  qui  peuvent  /aire  obstacle  d  V accoiichevient, 
p.  225.     These  de  concours.  Paris,  1878.) 


RETENTION    OF    THE   MENSES 


277 


displaced  fluid  is  not  distinct  as  in  ascites  or  in  a  cystic  tumour. 
The  fluctuation  is  all  the  more  obscure  because  the  uterine  walls  are 
not  only  distended  but  hypertrophied  by  the  repetition  of  expulsive 
contractions  caused  by  the  retention  of  the  blood  (Figs.  213 
and  214). 


Fig.  214. — Hypogastric  tumour  in  the  form  of  a  pilgrim's  gourd,  caused  by 
retention  of  the  menses  owing  to  imperforation  of  the  vulva ;  preparation 
in  the  EadclifEe  Museum  at  Oxford  ;  case  described  by  Tuckwell,  |  natural 
size ;  v,  distended  vagina ;  ou,  os  uteri  and  cavity  of  uterus  above  it 
equally  distended  ;  atresia  of  the  vulva  (after  Barnes). 

Lateral  hamatometra. — The  most  difficult  cases  to  diagnose  are 
those  of  complex  atresia,  i.  e.  occlusion  of  one  of  the  vagina  or  uteri 
forming  part  of  a  duplex  sexual  system  ;  because  whilst  the  patient 
has  all  the  symptoms  of  dysmenorrhoea,  she  nevertheless  has  her 
periods,  and  this  fact  removes  from  the  mind  of  the  physician  all 
idea  of  retention  of  the  menses.  However,  after  having  been  apprised 
of  the  repeated  occurrence  of  this  anatomo-pathological  anomaly, 
and  having  had  the  opportunity  of  seeing  a  drawing  of  it  as  given 
here,  it  would  be  inexcusable    to    ignore  the  possibility  of  its  ex- 


278 


UTEEINE    DISEASES    IN    DETAIL 


istence.  These  imperforations  of  one  of  the  halves  of  a  double 
genital  canal  have  been  met  with  11  times  in  the  uterine  canal  and 
23  times  in  the  vagina.     Out  of  28  cases  they  have  been  observed  20 


Fig.  215.— Max  Jacquet,  Ueter  Haematometra  bei  Uterus  duplex  {Zeitschrift 
fur  Gehurtshi'dfe  und  Frauenhranhheiten,  Bd.  i,  S.  134.  Stuttgart,  1875). 
Double  uterus  in  a  girl  of  fourteen  who  had  menstraated  for  some  months, 
and  who  succumbed  to  peritonitis  caused  by  retention  of  the  menses  in  the 
right  uterus  which  was  gi-eatly  distended,  and  in  which  a  thin  spot  c 
seemed  to  coiTespond  to  the  atresia  of  the  cervix  of  the  same  size.  The 
left  uteras,  which  is  open,  shows  the  arhor  vitce  ;  A  B,  the  longitudinal 
folds  of  the  vagina,  greater  behind  A  than  before  B  ;  vestiges  of  the  parti- 
tion between  the  piimitive  vaginse. 

times  on  the  right  and  8  times  on  the  left.  They  were  all  cases  of 
uienis  hicornis,  except  two  that  were  bilocular  or  divided.  The  most 
striking  symptoms  are  :  manifestation  of  the  pains  of  menstrual  re- 
tention coinciding  with  discharge  of  the  catamenia,  and  the  presence 
of  a  tumour  occupying  one  side  of  the  hypogastrium  and  a  large 
part  of  the  pelvic  cavity,  hindering  walking,  and  causing  dysuria  or 
retention  of  the  urine,  sometimes  fluctuating,  easily  defined  as  to  its 
superior  limits,  sometimes  reaching  the  vulva  below  and  pushing  the 
vao-inal  portion  of  the  cervix  of  the  other  side  upwards,  or  remaining 
in  the  pelvis  on  one  side  only,  pushing  the  cervix  of  the  other  uterus  to 
one  side,  or  forming,  on  a  level  with  the  urethra  (the  seat  of  the 
atresia)  a  spherical  tumour  which  projects  into  one  of  the  vaginal 
ctils-de-sac,  and  presses  laterally  against  the  open  cornu,  which  it 
pushes  upwards  and  to  one  side  till  it  appears  to  be  almost  surrounded 
by  it  (Eig.  218).  Any  pressure  on  the  hypogastric  tumour  is  trans- 
mitted to  the  vaginal  portion  and  vice-versa.^ 

'  Puech,  Annales  de  Gynecologie,  April,  June,  July,  August,  1875. 


RETENTION    OF    THE    MENSES  279 

These  symptoms  and  catheterism  of  the  open  cornu  ought  to  prevent 
anv  error  in  diagnosis.  Nevertheless,  unilateral  hsematometra  has 
been  taken  for  congestive  dysmenorrhcea,  peri-uterine  hematocele,  and 
even  an  ovarian  cyst.^  Sometimes  it  is  water  instead  of  blood  which 
fills  the  imperforate  cavity,  sometimes  it  is  pus,  sometimes  the  tumour 
is  uterine,  but  oftener  vagino-uterine.- 

These  are  the  most  usual  symptoms,  but  sometimes  there  are  others 
in  addition.  In  the  way  of  coi/iplications  we  may  mention  :  1,  dis- 
charges by  the  genital  canals;  2,  deviation  of  the  menses;  3,  hysteria; 
4,  chlorosis ;  5,  vagino-  and  utero-vesical  fistula. 

The  modes  of  termination  constitute  an  element  in  the  diagnosis. 
They  are  varied  and  depend  on  the  disturbances  which  the  presence  of 
an  obstacle  causes  in  menstruation.  1.  Deviation  of  the  menses  may 
be  more  than  a  symptom ;  it  may  also  be  a  mode  of  termination  of  the 
retention.  I  have  had  a  patient  in  whom  this  deviation  persisted 
throughout  life.  2.  The  obstacle  may  give  way,  either  by  bursting  (8 
cases)  or  by  gangrene  (4  cases).  As  a  rule,  the  former  mode 
occurs  where  the  obstacle  is  thin,  and  it  takes  place  after  violent 
colics.  I  have  once  seen  it.  3.  The  organs  containing  the  menstrual 
blood  are  dilated,  their  walls  become  thin  and  in  the  end  give  way. 
When  the  uterus  is  the  seat  of  this  rupture,  death  may  be  the  imme- 
diate consequence ;  three  cases  of  the  kind  have  been  observed. 
When  it  is  the  vagina  or  the  lower  part  of  the  cervix,  it  is  possible  for 
the  menstrual  blood  to  be  discharged  by  the  bladder ;  such  cases  have 
been  observed  by  Freteau,  Boyer  and  Desormeaux.  4.  Dilatation  of 
the  Fallopian  tubes  by  the  menstrual  blood  takes  place  sooner  or  later. 
It  is  caused  by  the  accumulation  of  blood  and  the  uterine  contractions 
forcing  the  orifices  of  the  Fallopian  tubes,  which  then  remain  open, 
owing  to  their  loss  of  contractility.  It  is  in  such  cases  that  the  sound, 
when  the  obstacle  has  been  removed,  has  been  known  to  enter  the  uterus 
and  penetrate  into  the  Fallopian  tube.  The  tumour  thus  formed  in 
the  Fallopian  tube,  especially  if  in  the  external  half,  may  attain  con- 
siderable proportions.  The  blood  thus  accumulated  may  be  expelled, 
either  by  flowing  backwards  through  the  ostia  uterina  (2  casesj  or  by 
exuding  through  the  fimbriated  extremity  into  the  peritoneum  (14 
cases).  Discharge  by  the  uterine  orifices  necessitates  previous  eva- 
cuation of  the  uterus ;  it  has  only  been  observed  by  Barnotte  and 
Amussat.  Discharge  by  the  fimbriated  extremity  is  generally  fatal. 
Amussat  and  Bernutz  alone  have  seen  patients  recover,  thanks  to  the 

*  Carl  Staude, "  Haematomeira  und  Haematoholpos  bei  zweigetheiltem  Utero- 
vaginal Canale.  Verwechsehing  mit  Tmnor  Ovarii.  Versuch  der  Ovariotomie, 
Seilnng."  The  patient  died  accidentally  six  months  afterwards,  when  the 
uterine  tumour,  caused  by  retention  of  the  menses,  was  discovered.  Zeitschrift 
fiir  Geburtsh.  und  Fraitenlcrank.,  Bd.  i,  S.  338.     Stuttgart,  1875. 

-  W.  A.  Freund,  Haematometra  und  Haematoholpos  lateralis  bei  Atresia 
eines  rudimentaren  Scheidenhanals  eines  Uterus  duplex,  in  Beitrdge  zur 
Geburtsh.  und  Gynaehologie,  Bd.  i,  S.  26.  Berlin,  1872.  Id.,  id.,  Beitrdge  zur 
Pathologie  des  doppelten  Genitalhanals,  in  Zeitschrift  fiir  Gtburtsh.  und 
Gynaehologie,  Bd.  i,  S.  231.  Stuttgart,  1877. — Breisky,  Fyometre  et pyoholpe 
lateral,  stiite  d'atresie  d'une  inoitie  de  vagin  rudimentaire  sur  un  uterus  septus. 
Archivf.  Gynaehologie,  Bd.  ii,  S.  24.     Berlin,  1871. 


280  UTERINE    DISEASES    IN    DETAIL 

encysting  of  the  blood  and  to  its  expulsion  through  the  rectum.  As 
for  the  other  cases  recorded^  death  occurred  so  rapidly  as  to  leave  no 
time  for  the  development  of  peritonitis.  Such  are  the  cases  of 
imperforate  hymen,  related  by  Brodie,  Moore  and  Paget ;  by  Boyer, 
Deces,  de  Haen,  Locatelli,  Maisonneuve  (2  cases),  Munck,  of  vaginal 
atresia ;  by  Hemman  and  de  Pauly  of  atresia  of  the  cervix.  I  have 
seen  a  woman  succumb  rapidly  to  peritonitis  caused  by  atresia  of  the 
cervix. 

In  lateral  hseraatometra  the  natural  terminations  are  similar  to  the 
preceding:  spontaneous  rupture  of  the  obstacle,  perforation  of  the 
septum  between  the  two  Pallopian  tubes  (Fig.  216),  passage  of  the 


Fig.  216. — Breisky,  Pyometra  and  Pyokolpos  due  to  atresia  of  one  half  of  a 
rudimentary  vagina  in  a  uterus  septus.  Archivfilr  Gynaehologie,  Bd.  ii,  S. 
48.  Berlin,  1871.  i'fZ,riglrt  vagina  ;  iff?,  right  uterus  filled  with  pus  ;  vg,leit 
vagina  ;  ug,  left  uterus  ;  o,  orifice  through  which  the  pus  retained  in-the 
right  utenas  was  discharged  externally  throu.gh  the  left  utems  and  vagina. 

blood  from  the  horn  into  the  Fallopian  tube,  and  from  this  into  the 
peritoneal  cavity,  peritonitis  caused  by  repeated  crises,  or  finally, 
passage  of  the  fluid  into  the  normal  uterus  and  vagina,  and  subsequent 
cure. 

In  all  these  cases  consumption  may  supervene  and  cause  death;  for 
dyspepsia,  vomiting,  continued  pain  and  constant  lessening  of  the 
interval  between  the  crises,  wear  out  the  best  constitution  and  lead  to 
marasmus.  Occasionally  the  menopause,  by  putting  a  stop  to  the 
discharge,  or  rather  to  the  sanguineous  fluxion,  at  the  same  time  puts 
an  end  to  all  accidents. 

To  sum  up,  a  cure  can  only  take  place  when  the  obstacle  gives  way. 
Tolerance  is  established  when  the  menses  are  deviated,  when  amenor- 
rhcea  supervenes,  or  when  the  menopause  is  established-  Apart  from 
these  exceptions,  there  is  always  danger  of  death,  and  as  nothing 
affords  any  indication  as  to  which  of  these  terminations  will  occur,  the 
wisest  course  is  to  avoid  all  by  opportune  intervention. 

Differential  diagnosis. — Without  having  any  pathognomonic  signs, 
strictly  speaking,  retention  of  the  menses  nevertheless  causes  a  number 
of  characteristic  symptoms,  such  as  absence  of  all  discharge,  the  coin- 
cidence in  time  between  the  commencement  of  the  symptoms  and  the 


RETENTION    OF    THE    MENSES 


281 


expected  advent  of  menstruation,  the  expulsive  nature  of  the  pains, 
their  duration  from  three  to  eight  days,  and  their  recurrence  after 
about  a  month's  interval,  their  localisation  in  the  loins,  hypogastrium 
and  perineum,  and  lastly,  the  appearance  of  a  tumour  either  at  the 
vulva  or  above  the  pubis,  or  in  both  places  simultaneously. 

When  all  these  symptoms  have  been  observed  it  is  easy  to  diagnose 
atresia ;  but  it  is  different  when  some  are  wanting  or  when  they  are 
not  well  marked.  In  such  cases  a  number  of  unjustifiable  mistakes 
are  sometimes  made :  menstrual  retention  from  atresia  confounded 
with  prolapsus  uteri,  sciatica,  ascites,  cystocele,  uterine  polypus, 
amenorrhoea,  or  even  with  pregnancy.  Sometimes  hsematocele,  pelvi- 
peritonitis and  purulent  tumours  of  the  pelvis,  ovarian  cysts,  hydatid 
cysts,  fibroma,  cancer  and  hydrometra  may  be  mistaken  for  retention, 
and  vice  versa.  Amenorrhcea  is  not  attended  by  periodical  exacerba- 
tions, nor,  above  all,  by  a  hypogastric  tumour.  In  pregnancy  the 
knowledge  of  the  antecedents,  the  mode  of  development  of  the  tumour, 
the  state  of  the  areola  of  the  breasts,  especially  if  the  patient  has  never 
had  children,  the  results  of  auscultation  (negative  in  retention,  positive 
in  pregnancy)  with  the  physical  signs  revealed  by  digital  examination, 
are  sufficient  to  establish  the  distinction.  There  is  one  feature  common 
to  hydrometra  and  hsematometra,  viz.  occlusion  of  the  cervix;  but 
special  and  distinctive  symptoms  also  always  exist :  hydrometra  is 
consecutive  to  amenorrhoea,  and  has  generally  a  slow  commencement ; 


tct'  ' 


Fig.  217. — Freund  of  Breslau,  two  cases  of  lateral  ha3inatometra  and  hfcmato- 
kolpos  from  atresia  of  a  rudimentary  vaginal  canal  of  double  uterus. 
Beitrdge  zur  Geburtshulfeund  Gynaekologie,  Bd.  ii,  Heft  i,  S.  26.  Berlin, 
1872.  Vertical  section  :  td,  i-ight  Fallopian  tube  ;  Ird,  right  round  liga- 
ment;  ovd,  right  vaginal  orifice;  av,  vaginal  atresia;  ^r/,  left  Fallopian 
tube;  Irg,  left  round  ligament;  ovg  left  vaginal  os  ;  li,  hymen. 


282 


UTERINE    DISEASES  IN    DETAIL 


accidental  hsematometra  begins  suddenly,  and  is  preceded  by  a  disease 
affecting  the  cervix.  The  course  of  development  of  the  tumour  is  not 
identical — in  the  first  it  takes  place  without  pain,  and  almost  con- 
tinuously ;  in  the  second  it  is  painful,  and  is  produced  in  monthly 
stages.  Lastly,  in  the  one  there  may  be  sanguineous  discharge,  in  the 
other  there  is  none. 

As  to  the  differential  diagnosis  of  various  hinds  of  atresia,  a  careful 
examination  enables  us  to  discover  the  special  characteristics  which  I 
have  already  pointed   out  in   describing  their   history.     It  will  be 


^o 


Fig.  218. — Id.  horizontal  section  :  av,  vaginal  atresia  ;  vo,  left  vagina  open. 

remembered  that  lateral  tumors  (haematometra,  hydrometra  or  pyo- 
metra),  in  cases  of  double  genital  system  usually  project  into  the 
normal  vagina  or  uterus  (Eig.  218),  so  as  to  be  partly  covered  by 
them  on  one  side,  and  to  jut  out  beyond  thera  on  the  other,  especially 
in  the  upper  part  corresponding  to  the  cornu  and  to  the  Fallopian  tube 
on  the  side  of  the  seat  of  obliteration  (Eig.  218). 

Treatment. — Out  of  the  great  number  of  cases  recorded  there  are 
eight  only  in  which  the  breaking  up  of  the  tumour  has  occurred  spon- 
taneously. The  age  of  the  patients  thus  cured  varies  from  18  to  22. 
The  time  is  that  of  a  paroxysm  :  the  necessary  prelude,  a  series  of 
violent  colics.  The  seat  of  the  obstacle  was  five  times  at  the  vulva,^ 
twice  at  the  vagina,^  once  at  the  cervix.^  In  four  cases  only  was  this 
natural  perforation  produced  by  gangrene  of  the  obstacle  under  the 
influence  of  continuous  pressure  of  the  accumulated  blood  and  of 
uterine  contractions.  In  that  recorded  by  Allaire  d^Hericy*  the 
symptoms  had  lasted  for  seventeen  months ;  the  tumour  was  the  size 

^  Wier,  De  prestigiis  dcemonum,  lib.  ii,  cap.  xxxviii. — Schenck,  Observa- 
tiones  medicce  rariores.  Lugduni,  1643,  lib.  iv,  p.  532. — Bartholin,  Centur.  v., 
Obs.  xliii. — Eschenbach,  Obs.  vied,  chir.,  p.  8. — Lafitte,  Revue  therapeutique 
du  Midi,  t.  X,  p.  44. — Scanzoni,  op.  cit.,  p.  476  :  "  A  girl  of  nineteen  suffered 
for  two  years  from  severe  dysmenorrhoea  due  to  imperforate  hymen,  when 
during  an  attack  of  pain  this  membrane  suddenly  ruptured  allowing  the  escape 
of  about  a  kilogramme  of  foetid  and  decomposed  blood.  Immediately  after  this 
accident  we  were  called  and  ascertained  that  the  rupture  had  taken  place ;  the 
hymen  hung  down  from  the  vagina  in  several  irregular  shreds." 

2  Delisle,  Journal  general  de  medecine,  t.  Ixvi,  p.  94.  It  may  be  admitted 
that  the  seat  of  the  second  obstacle  was  at  the  cervix. — Kiwisch,  in  Scanzoni, 
op.  cit.,  p.  487.     The  orifice  in  this  case  was  irregular  and  funnel-shaped. 

3  Puech,  op.  cit.,  obs.  xiv,  p.  56. 

*  Gazette  medicale  de  Paris,  1832,  p.  513. 


RETENTION    OF    THE    MENSES  283 

of  a  small  hen's  egg,  and  the  hymen  presented  two  blackish  points, 
the  one  at  the  centre,  the  other  at  the  side ;  the  latter  opened  first 
and  gave  issue  to  the  contents.  In  that  of  Demaux^  obliteration  of 
the  vagina  had  been  preceded  by  a  difficult  labour,  and  sounds  had  to 
be  used  to  dilate  the  opening  which  had  formed  in  the  centre  as  the 
result  of  sphacelus.  In  the  two  last^  gangrene  completed  the  opera- 
tion which  the  surgeon  had  not  the  courage  to  finish.  We  cannot, 
therefore,  count  on  the  eff'orts  of  nature  to  bring  about  a  happy  termi- 
nation to  a  disease  the  course  of  which  is  beset  with  dangers.  We 
must  not,  however,  conclude  that  operation  is  always  indicated.  We 
have  to  consider  the  real  dangers  incurred  by  operation,  the  still 
greater  perils  which  may  result  from  the  progress  of  the  disease,  as  well 
as  the  abolition  of  the  reproductive  functions  which  always  occurs. 
These  three  elements  of  the  question  are  evidently  the  three  principal 
sources  of  indication,  or  contra-indication,  to  the  active  intervention 
of  art.  The  elements  furnished  by  the  intensity  of  the  disease,  its 
seat  and  its  nature,  must  also  be  taken  into  account.  The  more  the 
organs  have  been  distended  by  the  menstrual  blood  and  the  more  they 
have  lost  their  power  of  contraction,  the  greater  likelihood  there  is  of 
metro-peritonitis  and  purulent  infection  finding  a  favorable  field  for 
development.  Whatever  the  size  of  the  tumour  may  be,  if  it  is 
bordered  by  one  or  two  small  lateral  tumours  formed  by  the  distension 
of  the  Fallopian  tubes,  we  have  reason  to  fear  a  fatal  result;  the 
operation,  perilous  as  it  may  be,  in  this  case  is  the  only  means  of 
preventing  death.  With  reference  to  the  seat  of  atresia,  imperforation 
of  the  hymen  and  membranous  occlusion  of  the  vagina  and  cervix 
may  be  classed  together  as  the  least  dangerous  forms ;  after  them  and 
in  order  of  increasing  gravity  come  partial  absence  of  the  vagina, 
complete  absence  of  this  organ,  and  lastly  absence  of  the  vagina  with 
imperforation  of  the  cervix.  Erom  another  point  of  view  operation 
as  a  rule  is  much  more  dangerous  in  acquired  than  in  congenital 
atresia. 

Whenever  an  operation  is  indicated  it  should  be  performed  as  soon 
as  possible,  as  delay  only  aggravates  the  danger  owing  to  the  increas- 
ing dilatation  of  the  uterus  at  every  monthly  period.  Operation  is  only 
absolutely  contra-indicated  when  the  uterus  is  atrophied  and  there  seems 
no  Hkehhood  that  the  menses  will  be  established;  before  operating 
therefore  we  must  ascertain  that  the  uterus  exists,  and  that  the  morbid 
symptoms  are  owing  to  distension  of  this  organ  and  not  to  any  other 
cause.  Operation  is  also  contra-indicated  when  the  existence  of  vesical 
or  rectal  fistulse  allows  the  escape  of  the  menses  by  the  urethra  or  anus. 
In  such  cases  intervention  should  only  be  resorted  to  when  the  operation 
is  easy  and  the  fistula  small  and  susceptible  of  cure  ;  here  also,  how- 
ever, there  is  not  strictly  speaking  retention,  and  therefore  the  opera- 
tion is  not  urgent.     The  age  of  the  patient  may  also  be  an  absolute 

1  Gazette  des  hopitaux,  1850,  p.  567. 

^  Barth,  Gazette  medicale  de  Strasbourg,  1844,  p.  221  :  Spontaneous  cure 
after  four  unsuccessful  operations. — Blandin,  Gazette  onedicale  de  Paris,  1846, 
p.  57.     Operation  causing  vesical  fistula ;  spontaneous  cure. 


284  UTEEINE    DISEASES    IN    DETAIL 

contra-indication ;  wliat  may  be  attempted  in  the  case  of  a  young 
woman  of  twenty  ought  not  to  be  thought  of  in  the  case  of  a  woman 
of  fifty.  Nevertheless  though,  as  a  rule,  it  is  wise  to  abstain  when  the 
menopause  is  established,  or  when  the  patient  has  reached  forty  and 
the  menstrual  periods  have  diminished  in  intensity,  yet  we  ought  to 
operate  after  this  age  when  blood-letting  and  opium  prove  ineffectual 
and  the  tumour  continues  to  progress  ;  for  women  of  fifty  and  upwards 
have  succumbed  in  such  cases  to  spontaneous  rupture  of  the  uterus.^ 
With  the  exception  of  such  cases  operation  is  indicated,  and  the 
sooner  it  is  had  recourse  to  the  better/"- Although  Boyer,^  Dupuytren,^ 
Capuron^  and  Cazeaux  ^  have  condemned  it,  it  seems  to  me  indicated 
within  Ihe  limits  just  stated.  The  distension  of  the  Fallopian  tubes  by 
the  menstrual  blood,  although  evidently  a  source  of  danger,  is  not  a 
contra- indication  :  on  the  one  hand  the  prospect  of  imminent  death,  on 
the  other  the  success  obtained  by  Amussat,  Debrou  and  Barnotte, 
authorise  active  intervention.  We  should,  however,  warn  the  parents  of 
the  risk  involved.  The  only  real  contra-indication  is  the  extent  of  the 
obstacle,  or  rather  the  extent  of  the  destructions,  the  length  and  narrow- 
ness of  the  vulvo-uterine  cicatrix  in  cases  of  accidental  obliteration,  in 
short  the  insurmountable  operative  difficulties. 

If  the  atresia  has  been  discovered  in  childhood  the  most  suitable  time 
for  operating  is  at  puberty,  just  before  the  appearance  of  the  menses. 
After  menstruation  is  established  the  indication  is  to  operate  as  soon  as 
possible.  Whatever  the  age  of  the  patient  may  be,  this  operation,  like 
all  others  on  the  uterus,  should  only  be  performed  in  the  intercalary 
period,  seven  or  eight  days  after  menstruation ;  at  this  time  the  con- 
gestion is  entirely  dissipated,  and  the  conditions  are  therefore  the  best 
possible  for  avoiding  inflammation. 

The  treatment,  essentially  surgical,  of  retention  of  the  menses  in- 
cludes two  important  indications: — (1)  To  give  free  passage  to  the 
blood  retained  above  the  obstacle  ;  (2)  to  maintain  the  patency  of  the 
opening  made. 

We  may  maJce  an  outlet  for  the  discharge  of  the  blood  in  two  ways, 
indirectly  or  directly.  The  indirect  method,  which  consists  in  attacking 
the  tumour  through  the  abdomen,  the  bladder  or  the  rectum,  is  only 
admissible  in  cases  of  complete  absence  of  the  vagina,  where  it  is  im- 
possible to  reach  the  uterus  through  the  recto-vesical  space.  The  best 
of  these  three  indirect  ways  is  evidently  the  rectum.  I  confess,  how- 
ever, that  it  seems  to  me  more  applicable  to  cases  of  atresia  of  the 
hymen  or  lower  part  of  the  vagina  than  to  those  of  the  uterus,  and  in 
this  case  it  is  easier  to  open  the  tumour  directly  through  the  vulva. 
Although  this  operation,  which  was  performed  for  the  first  time  un- 
successfully by  Dubois,^  has  been  repeated  in  our  days  by  Oldham, 

'  Duparque,  Traite  des  ruptures  de  la  matrice.    1839,  p.  13,  14. 

^  Traite  des  malad.  chirurg.,  t.  x,  p.  447,  4e  edit.     Paris,  1831. 

^  Quoted  by  Pigne,  Traite  des  chirurg.,  of  Chelius,  t.  ii,  p.  62. 

■*  Bulletin  de  I'Acad.  de  med.,  13th  Sept.,  1839. 

°  Gazette  des  hopitaux.   1861,  p.  31. 

^  See  Boyer,  Traite  des  malad.  chirur,,  t.  x,  p.  447. — Boivin  et  Duges,  op. 


EETENTION    OF    THE    MENSES  285 

Baker-Brown,  and  Hastings-Hamilton,  who  penetrate  from  the  rectum 
into  the  tumour  by  means  of  a  curved  trocar,  I  cannot  refrain  from 
remarking  that  the  operator  risks  piercing  the  peritoneum  twice,  and 
that,  in  order  to  prevent  the  consequences  of  the  blood  remaining  in 
the  uterus  or  vagina,  its  effusion  into  the  peritoneum  is  encouraged, 
whilst,  even  in  case  of  success,  all  that  is  gained  is  a  utero-  or  vagino- 
rectal  fistula;  with  which,  if  it  occurs  spontaneously,  we  must  be 
contented,  but  which  is  not  desirable  when  gained  at  the  risk  of 
life. 

The  direct  metliocl  consistajP^  attacking  the  tumour  through  the 
vulva  and  in  establishing  a  lasting  communication  between  the  one  and 
the  other.  This  method  alone  satisfies  all  indications,  for,  by  pre- 
venting accidents,  it  brings  the  parts  back  to  their  natural  condition. 

Cauterisation  has  been  tried,  but  without  success,  by  Felix  Plater  ^ 
and  Gaspard  Bauhin.^  Caustics  in  fact  have  inconveniences  which  are 
not  compensated  by  any  advantage ;  it  is  difficult  to  use  them,  and 
impossible  to  limit  their  action,  and  the  orifice  is  made  at  the  cost  of 
a  more  or  less  considerable  loss  of  substance  and  of  the  inevitable 
formation  of  cicatricial  tissue.  On  the  contrary,  incision  and  tearing, 
either  alone  or  aided  by  dilatation,  are  the  most  suitable  means  for 
opening  up  a  vulvo-uterine  passage,  incisions  or  puncture  sufficing  for 
thin  membranous  occlusions,  incision,  dissection  and  dilatation  being 
necessary  for  obliterations  of  considerable  depth.  As  the  modes  of 
procedure  vary  according  to  the  resistance  of  the  obstacles,  I  will 
describe  the  manner  of  performing  each  operation  successively. 

The  bladder  having  been  emptied  by  means  of  a  catheter,  and  the 
rectum  by  an  enema,  the  patient  should  lie  on  her  back  on  the  edge  of 
the  bed,  opposite  a  window,  in  the  position  required  for  examination 
by  speculum,  the  pelvis  raised,  the  thighs  and  legs  flexed  and  apart. 
An  anesthetic  should  be  given,  unless  especially  contra-indicated; 
and,  in  most  of  these  operations,  the  bladder  should  be  raised  by 
means  of  a  sound  introduced  into  its  cavity  and  the  rectum  should  be 
drawn  down  by  the  index  finger, 

I,  Imperforate  hymen. — The  plan  which  seems  to  me  the  best  is  the 
following,  proposed  by  Puech.^  Having  made  the  hymen  bulge  out, 
the  centre  is  seized  with  forceps,  whilst  the  right  hand,  with  curved 
scissors  or  bistoury,  removes  a  circular  piece  of  membrane.  The  genital 
organs  are  then  explored  with  the  index  finger,  a  gutta-percha  bougie 
of  medium  size  being  afterwards  substituted  for  the  finger  to  close  the 
opening.  By  this  means  the  blood  is  prevented  from  gushing  out  and 
the  uterine  and  vaginal  cavities  are  enabled  to  recover  their  normal 
condition,  whilst  the  air,  having  greater  difficulty  in  penetrating  into 
the  uterine  cavity,  exerts  a  less  injurious  influence  on  it.  As  a  rule, 
this  operation  is  not  followed  by  any  serious  consequences  ;   but  we 

cit.,  t.  i,  p.  272.  Congenital  absence  of  the  vagina.  Puncture  by  the  rectum. 
Peritonitis  ending  in  death. 

'  Observationum ,  lib.  iii.     Basileaj,  1614,  lib.  i,  p.  241. 

^  Theatrum  anatomicnm.     Paris,  1621,  lib.  i,  cap.  xxxix,  p.  1.S3. 

3  Op.  cit.,  p.  98. 


286  UTEEINE   DISEASES   IN   DETAIL 

must  not  forget  that  metro-peritonitis  may  occur  and  cause  deaths  as 
has  happened  twice  out  of  135  operations.^ 

II.  Atresia  of  the  vagina. — In  cases  of  membranous  imperforations, 
a  trocar  or  straight  bistoury  is  plunged  into  the  obstacle^  and  incisions 
are  made  in  various  directions  till  the  finger  passes  easily.  In  more 
extensive  atresise  there  are  various  modes  of  procedure,  but  only  two 
deserve  description. 

1.  The  plan  followed  by  Amussat^  in  1832  consists  in  more  or  less 
violent  pressure  exercised  by  the  finger  or  a  soft  body,  with  the  object 
of  pressing  the  vulval  mucous  membrane  into  the  groove  corresponding 
to  the  entrance  of  the  absent  vagina.  After  a  time  this  yields,  and 
after  several  attempts,  repeated  at  longer  or  shorter  intervals,  the 
tumour  is  reached,  when  the  last  barrier  may  be  removed  by  the  trocar. 
This  plan  is  more  seductive  than  perfect.  It  can  neither  be  employed 
in  accidental  atresia,  nor  in  cases  where  the  rectal  and  vesical  walls  are 
separated  by  a  tissue  of  much  resistance.  It  is  very  slow.  Amussat 
required  six  sittings  and  ten  days  to  reach  the  uterus  ;  Parey^  four 
sittings  and  thirteen  days,  besides  which,  after  the  second  sitting,  the 
sensibility  was  so  great  as  to  make  the  latter  attempts  very  painful. 
The  patient  operated  upon  by  Bernutz*  was  discouraged  after  five 
attempts,  in  spite  of  her  great  desire  to  be  cured. 

3.  Dupuytren^s  plan  ^  consists  in  the  use  of  the  bistoury,  combined 
with  separation  of  the  cellular  tissue.  It  is  effected  in  a  single  sitting. 
The  following  is  the  description  of  it  as  modified  by  Puech,^  By  means 
of  a  male  catheter  the  bladder  is  kept  raised.  The  index  of  the  left 
hand  is  then  passed  as  far  into  the  intestine  as  possible  to  guide  the 
bistoury  and  to  protect  the  rectum.  A  transverse  incision  is  then 
made  in  the  centre  of  the  obstacle,  or  in  the  vulval  fossa  if  the  vagina 
is  entirely  absent ;  when  the  cellular  tissue  is  loose,  the  operator  may, 
with  the  finger,  catheter,'^  or  handle  of  the  bistoury,  separate  the  vesical 
and  rectal  walls  till  the  tumour  is  reached ;  when  it  is  thick  or  very  re- 
sistant it  must  be  carefully  dissected,  separating  the  tissues  with  the 
handle  or  the  finger  rather  than  cutting  them,  and  when  necessary 
cutting  with  a  probe-pointed  bistoury.  The  operator  must  proceed 
slowly  and  circumspectly,  stopping  occasionally  to  examine  with  the 
finger  to  ascertain  how  far  he  is  from  organs  that  must  be  avoided. 

1  shall  merely  mention  electricity,  as  it  has  been  said  to  possess  the 
property  of  causing  extensile  in  place  of  retractile  cicatricial  tissue; 
this  however  has  not  been  proved.     When  the  newly-formed  canal 

^  Quesnay  in  tis  paper  8ur  les  vices  des  humeurs,  printed  in  the  Memoires 
de  VAcademie  de  chirurgie  (1743,  pp.  58,  59),  characterises  the  blood  which 
issues  from  the  vagina  after  operations  for  atresia  of  the  hyrnen  as  being  black, 
thick,  often  inodorons,  but  sometimes  foetid  (De  la  Motte,  Epliemerides  d'Al- 
lemagne,  Benivenius,  Merch'ren,  Aquapendente). 

2  Gazette  Medicate  de  Paris,  1835,  p.  785. 

3  Gazette  des  hopitaux,  1861,  p.  69. 

4  Op.  cit.,  t.  i,  p.  307. 

*  Sabatier,  Theses  de  Paris,  1848,  no.  68,  p.  40. 

6  Op.  cit.,  p.  106. 

7  Fletcher,  Medico-surgical  Notes  and  Illustrations.  London,  1831,  p.  143. 
— Archiv.  gen.  de  med.,  1835,  t.  vii,  p.  549. 


RETENTION  OF  THE  MENSES  287 

admits  the  index  iinger  easily,  and  when  a  clearer  perception  of  fluctua- 
tion apprises  the  surgeon  of  the  proximity  of  the  collection  of  blood, 
he  may  plunge  the  trocar  into  it,  and  the  issue  of  a  brown  syrupy  fluid 
will  prove  to  him  that  he  has  succeeded.  A  small  quantity  of  the 
fluid  is  allowed  to  escape  by  the  canula.  This  little  orifice  will  only 
be  enlarged  after  some  time  to  ensure  the  final  result.  A  few  days 
afterwards  a  gutta-percha  catheter  is  to  be  introduced  into  the  uterine 
cavity,  and  injections  of  tepid  water  with  a  few  drops  of  carbolic  acid 
are  to  be  made  through  it.  A  small  syringe  should  be  used,  and  the 
injections  should  be  made  with  great  precaution.  The  dressing 
finished,  the  parts  are  sponged  and  wiped  and  the  patient  placed  in 
bed,  care  being  taken  to  protect  the  bedding  from  being  soiled  by  the 
black  blood  and  mucous  discharge  which  will  be  excreted  for  some 
days. 

This  method  is  applicable  to  all  cases  ;  only  the  use  of  the  finger 
or  soft  instruments  may  be  limited  according  to  circumstances,  some- 
times not  being  required  at  all.  If  it  is  logical  to  distinguish  cases 
of  this  kind  (the  most  serious,  and  those  which  cause  most  acci- 
dents), it  is  unnecessary,  with  Verneuil,i  to  adopt  a  different  plan  for 
them. 

Accidents  attending  the  operation. — Roonhuysen,^  Benevoli,^  Liston,'* 
the  surgeon  quoted  by  DiefFenbach"  and  Barth^  were  obHged  to  leave 
the  operation  unfinished ;  Roonhuysen  and  the  surgeon  quoted  by 
Dieffeubach  because  they  had  involved  the  rectum  and  the  others 
from  want  of  courage.  On  one  occasion  I  was  unable  to  terminate 
an  operation  of  this  kind.  The  blending  of  the  bladder  and  rectum 
was  so  complete  at  a  certain  depth  that  it  would  have  been  imprudent 
to  have  continued,  for  it  was  impossible  to  attempt  to  separate  the 
one  from  the  other.  The  menstrual  retention  w^as  caused  by  a 
cicatricial  occlusion  of  the  whole  vagina  consecutive  to  gangrenous 
suppuration  after  a  confinement.  The  patient  was  stout,  extremely 
sensitive  with  regard  to  the  consequences  of  her  infirmity,  and 
threatened  by  the  accidents  which  often  accompany  retention.  From 
that  time  the  symptoms  were  gradually  mitigated,  and  although  the 
menstrual  molimen  and  ovarian  activity  were  more  or  less  felt 
every  month,  there  was  no  accumulation  of  blood  in  the  uterus,  no 
deviation  of  the  menses,  nor  any  other  pathological  phenomenon, 
thanks  to  the  palliative  treatment  prescribed  and  to  the  progressive 
tolerance  of  the  organism. 

The  bladder  has  been  injured  three  times  :  in  one  case  a  cure  was 
effected  ;  in  another  a  vesico-vaginal  fistula  was  formed  which  Blandin 
could  not  cure;  and   another  time   (de  Haen),  apart  from  the  fistula, 

*  Rapport  a  la  Societe  de  chirurgie  sur  V operation  de  M.  Patry  {Gazette 
des  hupitaux.    1861,  p.  69). 

2  Observ.  med.  rariores  Gerardi  Blasii.     Amstelodami,  1677,  p,  30. 

^  Related  by  Chainbon  and  by  Colombat. 

■•  Gaz.  des  hupitaux,  1839,  p.  183. 

*  Related  by  Verneuil,  Gaz.  des.  hop.,  1861,  p.  31. 
^  Gazette  med.  de  Strasbourg,  1844,  p.  222. 


288  UTERINE    DISEASES   IN    DETAIL 

death  occurred  by  the  effusion  of  menstrual  blood  into  the  peritoneum 
through  the  Fallopian  tubes. 

Hsemorrhage  is  rarely  serious ;  but  it  may  become  troublesome. 
This  has  led  Camerarius^  Voisin  and  Guerin  to  make  several  short 
operations.  In  this  case  it  is  necessary  in  order  not  to  lose  the 
benefit  of  the  first  incisions,  to  insert  a  foreign  body,  or  even  a  dilator, 
in  the  canal  that  has  been  hollowed  out. 

The  consecutive  accidents  which  may  occur  are  varied :  metritis, 
inflammation  of  the  Pallopian  tubes,  peritonitis,  and  even  putrid  in- 
fection. Out  of  66  operations  there  were  6  cases  of  death  due  to 
the  three  last  diseases. 

I  am  convinced  that,  in  accidental  obliterations  due  to  puerperal 
gangrene  of  the  vagina,  the  tendency  of  inflammations  to  assume 
the  gangrenous  character  may  be  the  cause  of  fatal  symptoms,  just  as 
it  produced  the  first  accident  and  the  deformity  which  necessitated 
the  operation.  I  lost  a  patient  in  this  way.  After  great  difiiculties, 
and  even  a  little  tearing  of  the  peritoneal  cul-de-sac  in  front  of  the 
rectum,  I  reached  the  uterus,  and  things  progressed  so  well  for  some 
days  that  we  had  hopes  of  success,  when,  concurrently  with  a  slight 
attack  of  peritonitis  easily  subdued  by  treatment,  gangrene  of  the 
walls  of  the  new  canal  showed  itself,  which  yielded  to  no  tonic,  nor 
to  any  injection  detersive,  antiseptic,  stimulating,  nor  catheretic,  and 
which  finally  caused  death  on  the  fifteenth  day. 

Eelapse  has  been  observed  four  times.  It  is  due  to  the  insufficiency 
of  the  operation,  to  inflammation  of  the  parts,  or  to  neglect  of 
dressing.  Contraction  of  the  canal  due  to  the  same  causes  has  been 
observed  nine  times. 

To  sum  up,  the  results  are  as  follows  : — Out  of  28  operations  for 
congenital  atresia  2  were  not  terminated,  and  2  had  to  be  repeated 
owing  to  relapses.  There  were  6  deaths,  4  of  which  were  owing  to 
the  reflux  of  uterine  blood  j  leaving  these  out  of  the  calculation, 
there  were  2  deaths  in  24  cases.  Out  of  33  cases  of  accidental 
atresia,  8  operations  were  not  terminated  or  had  to  be  repeated ;  there 
were  6  deaths,  one  of  which  was  owing  to  a  reflux  of  uterine  blood, 
and  another  to  intercurrent  pleurisy ;  putting  these  aside  there  re- 
main 4  deaths  in  31  cases,  a  greater  mortality  than  in  congenital 
atresia. 

3.  The  author's  method.  I  usually  prefer  rapid  operation  with 
the  bistoury  for  accidental  atresia  ;  but  for  congenital  atresia  I  greatly 
prefer  the  slow  operation  by  means  of  small  incisions  combined  with 
the  use  of  sponge  tents  of  gradually  increasing  size,  and  the  pro- 
longed issue  of  blood  drop  by  drop.^ 

^  I  have  lately  had  occasion  to  congratulate  myself  on  the  success  of  this 
method  in  a  young  lady  suffering  from  vaginal  atresia.  Sponge  tents  intro- 
duced into  small  incisions  made  every  week  of  increasing  depth  allowed  of  my 
reaching  the  cervix  which,  owing  to  gradual  cicatrisation  of  the  wound  after 
every  operation,  was  at  last  drawn  down  to  a  level  with  the  lower  part  of  the 
vagina,  the  only  part  originally  existing.  Ti-eatment  lasted  six  months.  It 
was  followed  some  months  afterwards  by  pregnancy  which  terminated  in 
natural  delivery.     I  performed  the  same  operation  successfully  on  a  girl  last 


RETENTION    OP    THE    MENSES  289 

III.  Absence  of  vagina  and  imperforate  cervix. — lu  this  kind  of 
atresia,  the  difficulty  is  to  free  the  cervix;  to  effect  this  the  circum- 
ference of  this  organ  should  be  detached  from  the  surrounding  parts 
with  the  finger  or  a  soft  instrument,  after  a  vagina  has  been  made. 
In  order  to  prevent  the  recurrence  of  the  uterine  atresia,  which 
Debrou  and  Patry  have  observed,  Puech^  recommends  two  operations. 
In  the  first,  the  vagina  is  to  be  formed ;  in  the  second,  two  months 
afterwards,  the  uterus  is  attacked.  This,  of  course,  is  only  possible 
when  the  symptoms  are  not  alarming. 

IV.  Atresia  of  the  cervix. — Different  instruments  may  be  used  for 
attacking  this  obstacle :  the  straight  or  curved  trocar,  Pleurant's 
trocar,  Priar  Comers  pointed  sound,  the  pharyngotome,  Thomas's 
lithotome,  Plamand^s  hysterotome,  the  ordinary  straight  and  probe- 
pointed  bistouries. 

The  first  time  I  had  occasion  to  perform  this  operation,  about  thirty 
years  ago,  I  had  a  grooved  sound  made  about  30  centimetres  long, 
and  fitted  on  to  a  wooden  handle  which  was  roughened  on  the  side 
corresponding  to  the  groove.  I  had  also  two  bistouries  made  of 
the  same  length,  one  sharp-pointed,  the  other  probe-pointed,  both 
sharp  only  to  the  extent  of  2  centimetres  at  the  extremity.  The 
cervix  having  been  seized  and  fixed  with  the  help  of  the  speculum, 
I  punctured  it  with  the  pointed  bistoury  at  the  spot  where  a  depres- 
sion was  to  be  seen,  and  pushed  the  instrument  in  the  direction  of 
the  axis  of  the  cervix  to  the  depth  of  15  millimetres ;  I  then  intro- 
duced the  grooved  sound,  and  succeeded  in  making  it  penetrate  into 
the  uterine  cavity,  where  I  felt  that  it  moved  freely  enough  to  make 
sure  that  it  must  have  penetrated.  I  next  introduced  the  probe- 
pointed  bistoury  into  the  groove  of  the  sound,  and  having  directed 
it  alternately  to  both  sides,  before  and  behind,  I  made  an  incision  of 
some  millimetres  in  length  and  of  about  3  centimetres  in  depth, 
around  the  artificial  orifice  first  made.  Except  a  slight  discharge  of 
red  blood  caused  by  the  incisions,  only  a  few  drops  of  black,  thick, 
viscid  blood  escaped ;  but  I  was  not  in  the  least  surprised,  for  the 
body  of  the  uterus  was  not  dilated,  and  the  patient  suffered  from  a 
deviation  of  the  menses,  constituting  a  supplementary  menstruation. 
No  accident  occurred ;  every  day  I  introduced  a  gutta-percha  sound 
of  increasing  size,  and  the  patient  was  soon  able  to  leave.  I  have 
since  heard  that  her  cure  has  proved  permanent.  Since  that  time  a 
pointed  sound  has  been  invented,  as  well  as  various  concealed  hystero- 
tomes  with  two  blades,  analogous  to  small  lithotomes  which  I  have 
already  described  as  applicable  to  this  operation,  as  well  as  to  simple 
incision  of  the  cervix  in  cases  of  constriction  of  the  os.  I  have  used 
them  for  three  operations  of  the  same  kind ;  one  in  a  virgin,  for 
imperforation ;  two  others  for  obliterations  occurring  after  labour, 
summer.  After  having  reached  the  uterus  with  difficulty  from  the  viUva 
through  an  imperforate  vagina,  I  made  a  puncture  by  whicli  all  the  blood 
issued  from  the  uterus  in  fifteen  days  without  any  accident,  thanks  to  frequent 
injections  of  hot  water  and  carbolic  acid.  It  was  only  later  that  I  dilated  the 
orifice. 

^  Op.  cit.,  p.  118. 

19 


290  UTERINE    DISEASES    IN    DETAIL 

As  to  congenital  constriction  and  contraction  taking  place  after  con- 
finements, they  occur  very  frequently,  as  we  shall  see  when  consider- 
ing mechanical  dysmenorrhoea.  In  such  cases,  however,  simple 
incision  is  often  insuf&cient,  and  recourse  must  be  had  to  one  of  the 
operations  for  autoplasty  of  the  orifice,  which  I  shall  describe  when 
we  come  to  the  surgical  treatment  of  dysmenorrhcea.  Usually  the 
operation  ought  to  be  performed  in  the  following  way  :  the  cervix  is 
brought  into  view  and  fixed  by  a  Pergusson's  speculum ;  then  with  a 
narrow-pointed  bistoury  a  puncture  is  made  at  the  spot  where  a  de- 
pression indicates  the  primitive  or  probable  position  of  the  meatus. 
We  have  reason  to  believe  that  the  uterine  cavity  is  reached  when 
there  is  a  sensation  of  resistance  overcome,  and  at  the  same  time  there 
oozes  out  a  drop  of  brown,  syrupy  fluid.  I  do  not  enlarge  the  orifice 
by  small  incisions  made  in  every  direction,  nor  do  I  allow  the  accumu- 
lated fluid  to  escape  till  much  later.  I  introduce  every  day  a  gutta- 
percha sound  into  the  uterine  cavity,  through  which  I  inject  small 
quantities  of  hot  water  and  carbolic  acid.  If  puncture  and  incisions 
are  insuflicient  recourse  must  be  had  to  autoplasty. 

The  immediate  accidents  are  nil,  and  the  consecutive  accidents  are 
identical  with  those  I  have  described  under  vaginal  atresia  ;  peritonitis 
and  purulent  infection  have  caused  death  three  times,  Eelapse  is 
frequent :  seven  patients  have  been  cured  only  after  a  second  opera- 
tion, and  in  two  a  third  operation  was  rendered  necessary.  It  is  on 
that  account  that  autoplasty  is  often  indispensable. 

To  sum  up,  53  operations  have  been  performed  on  41  women,  and 
among  these  there  were  3  deaths  and 38  permanent  cures;  25  cures  of 
congenital  atresia  and  2  deaths,  13  cures  and  1  death  in  cases  of 
accidental  atresia. 

Dressing. — It  is  not  enough  to  operate  and  make  an  outlet  for  the 
menstrual  retention;  accidents  must  be  prevented,  and  above  all  the 
artificial  orifice  or  newly-made  canal  must  be  kept  open. 

In  order  to  p-event  accidents  the  discharge  of  the  fluid  must  be 
regulated.  Left  to  itself  it  is  sometimes  too  rapid,  giving  rise  to 
syncope  and  other  accidents,  due  to  the  absence  or  exaggeration  of 
uterine  contraction;  sometimes  it  is  too  slow,  in  which  case  the 
action  of  the  air  may  cause  putrefaction  of  the  retained  fluid.  To 
prevent  this  antiseptic  injections  should  be  made  twice  a  day  for  a 
fortnight.  If  decomposition  of  the  blood,  entrance  of  air,  or  suppu- 
ration give  rise  to  a  putrid  discharge  the  uterine  cavity  should  be 
gently  washed  out  with  disinfectants.  In  order  to  p-eserve  the  artificial 
canal  or  orifice,  Puech^  recommends  the  introduction  of  india-rubber 
bougies,  the  upper  third  of  which  should  be  covered  with  linen  to 
prevent  slipping.  In  a  case  of  cervical  atresia  the  bougie  or  sponge 
tent  should  be  fixed  with  pledgets  of  lint,  and  the  whole  kept  in  place 
with  a  T  bandage.  The  bougie  and  dressing  should  be  changed  every 
day  or  two  till  the  discharge  has  ceased  'and  the  injections  are 
unnecessary.  In  order  to  fit  the  vagina  for  fulfilling  its  functions> 
the  canal  ought  to  be  dilated  by  applying  sponge  tents  of  gradually 
»  Op.  cit.,  p.  126. 


DETENTION   OP  THE    MENSES  291 

increasing  size,  after  convalescence  has  been  established.  These  appli- 
cations should  be  suspended  during  the  monthly  period ;  but  when  it 
is  over  the  canal  should  be  examined  by  speculum,  so  as  to  destroy  any 
adhesions  that  may  have  been  formed.  We  can  only  be  sure  of  the 
result  when  the  walls  of  this  canal  are  covered  by  a  rose-coloured 
membrane  analogous  to  the  rest  of  the  mucous  membrane.  As  a 
rule,  dilatation  need  not  be  continued  longer  than  three  or  four 
months. 

In  a  successful  case  the  ulterior  consequences  are  most  favorable. 
By  acting  on  the  local  state,  making  an  outlet  for  the  retained  fluid, 
and  removing  the  cause  of  the  crises,  the  operation  exercises  a  most 
beneficial  influence  on  the  general  economy.  The  patient  soon 
recovers  her  strength,  menstruation  is  established  and  recurs  regularly 
without  producing  either  disturbance  or  pain.  Sterility  disappears 
with  the  cause  which  occasioned  it,  women  sometimes  becoming 
pregnant  soon  after  the  operation ;  and  Puech  has  proved  by  numerous 
examples,  that  parturition  may  occur  without  laceration. 

Can  we  count  on  the  restitution  of  a  true  vagina  ?  It  is  to  be  feared 
that  the  result  will  be  but  unsatisfactory  when  there  is  little  or  no 
vestige  of  vaginal  mucous  membrane  between  the  uterus  and  vulva. 
Willaume  de  Metz^  and  Amussat  obtained  a  fistula  rather  than  a 
vagina.  Even  this  result  is  useful  because  it  allows  menstruation  to 
take  place  and  puts  a  stop  to  the  accidents  of  retention.  But  it 
cannot  be  hoped  that  the  woman  will  thereby  be  fitted  for  marital 
intercourse,  and  still  less  for  childbearing.  Although  very  extra- 
ordinary cases  of  this  kind  have  been  recorded,  we  must  not  forget 
that  serious  accidents  are  to  be  feared  at  parturition,  as  in  Debrou^s^ 
curious  case,  that  the  child  may  be  expelled  through  the  perineum, 
that  the  recto-vaginal  septum  may  be  torn,  or  that  the  uterine  pains 
may  diminish  or  cease  altogether,  &c.  These  dangers  are  especially 
to  be  feared  after  operations  for  accidental  atresia,  when  cicatricial 
tissue  replaces  the  destroyed  vagina.  It  is  said  that  electricity 
prevents  the  formation  of  this  retractile  tissue,  but  hitherto  this  fact 
has  not  been  placed  beyond  doubt. 

If  portions  of  the  vagina  are  left,  i.e.  of  mucous  membrane  which 
can  be  reunited,  permitting  the  re- establishment  of  a  distensible 
canal  between  the  uterus  and  vulva,  we  may  hope  that  in  spite  of 
cicatricial  tissue  and  partial  contractions  following  suppuration  after 
the  operation,  there  may  be  a  sufficiency  of  dilatable  material  to 
enable  it  to  fulfil  its  functions  though  in  an  imperfect  manner.  There 
are  many  cases,  however,  which,  though  calling  for  operation,  in  order 

*  Bevue  medicate  franpaise  et  etrangere,  182G,  t.  iii,  p.  168. 

'  Fibrous  coarctation  of  the  whole  vagina ;  imperforation  oE  the  cervix.  The 
83'mptoms  began  at  seventeen.  At  nineteen  distension  of  the  uterus  and  right 
Fallopian  tube.  First  operation  :  establishment  of  the  vaginal  canal  and  of 
the  uterine  orifice.  Eelapse  after  two  months.  Second  operation  followed  by 
complete  success.  Pregnancy,  labour  at  natural  term,  eclampsia.  Application 
of  forceps  ;  child  stillborn.  Fatal  peritonitis  {Gazette  mklicale  de  Paris,  ISolj 
p.  32). 


292  UTERINE    DISEASES    IN    DETAIL 

to  prevent  the  fatal  results  of  retention^  yet  demand  that  we  sliould 
warn  the  patient  of  the  risk  she  would  run  by  attempting  a  renewal  of 
marital  intercourse. 

Lastly,  in  cases  where  it  is  not  possible  to  undertake  an  operation, 
we  must  content  ourselves  with  palliative  treatment.  This  exclu- 
sively medical  treatment  ought  indeed  to  be  prescribed  in  every  case, 
in  order  to  prevent  the  accidents  of  retention  till  such  time  as  the 
operation  can  be  performed.  It  consists  in  fulfilling  two  indications 
which  present  themselves  in  the  treatment  of  some  other  menstrual 
disorders,  especially  in  uterine  fluxion,  deviation  of  the  menses,  in 
nervous  dysmenorrhoea,  in  painful  and  violent  uterine  contractions, 
and  in  imminent  peritonitis.  These  indications  are  :  to  revulse,  or 
turn  aside  the  fluxionary  movement  by  bloodletting,  purgatives  and  other 
revulsives  employed  methodically,  in  order  to  prevent  distension  of 
the  uterus  by  a  fresh  flow  of  blood  every  month ;  to  allay  pain  and 
irritability,  and  to  diminish  uterine  contractions  by  opiates  and  nar- 
cotics, in  the  form  of  opiate  enemata,  chloroform,  &c.  Secondary 
indications  may  arise  in  different  cases,  according  to  the  special 
symptoms  which  may  present  themselves. 

Deviation  of  the  Menses  and  Supplementary  Menstruation. 

The  various  terms,  deviation  of  the  memes,  supplementary  hamor- 
rJiages,  menses  per  aliena  loca,per  vias  insolitas  erumpentes,  menorrliagia 
erronea,  menstruatio  vicaria,  ecfopie  or  lieierotopie  menstruelle,  all 
signify  a  discharge  of  blood  occurring  at  periodical  times,  from  other 
organs  than  the  uterus.^  This  abnormal  phenomenon  sometimes 
replaces  the  catamenia,  at  other  times  it  occurs  simultaneously 
with  this  discharge  which,  however,  is  then  greatly  diminished. 
The  two  varieties  ought  to  be  distinguished  by  different  names :  the 
term  deviation  of  the  mensesl  s  used  when,  in  the  absence  of  the 
catamenia,  a  more  or  less  abundant  hemorrhage  occurs  almost  every 
month  from  some  other  part  of  the  body ;  supplementary  menstruation 
may  be  used  in  the  same  circumstances,  but  rather  when  an  insignifi- 
cant discharge  occurs  simultaneously  from  the  uterus. 

Ameuorrhoea  is  the  only  disease  which  can  produce  this  morbid 
condition.  Menstrual  retention  very  seldom  does  so,  only  four  times 
in  258  cases. ^  The  reason  is,  that,  in  amenorrhosa,  it  is  not  the 
defective  evacuation,  but  the  cessation  of  the  fluxionary  movement 
towards  the  uterus  and  its  change  of  direction  which  can  deviate  the 
menses  and  produce  haemorrhage  in  some  other  part  of  the  body 
after  an  unwonted  fluxion  and  congestion.  There  may  not  even  always 
be  haemorrhage;  there  may  only  be  more  or  less  sudden  or  durable 
fluxion  towards  an  organ,  congestion  of  its  tissue,  a  slight  sanguineous 

1  A.  de  Haller,  Elementa  pliysiologue,  t.  vii.  Lausanne,  1778,  lib.  xiviii, 
sect,  iii,  §  14.  Qucc  mensmm  locuvi  tenent.  The  great  physiologist  points 
out  in  a  few  lines  all  parts  of  the  body  by  which  the  blood  may  be  discharged 
when  hindered  from  issuing  by  the  uterus. 

"  Puech,  Acad,  dea  sc,  seance  du  9  dec,  1861. 


DEVIATION    OF    THE    MENSES 


293 


interstitial  effusion  or  ecchymosis/  or  the  production  of  another 
discharge. '-^ 

This  phenomenon  attracted  special  attention  in  former  ages,  when 
there  was  a  tendency  to  believe  in  the  marvellous.  If  in  those  times 
people  were  disposed  to  be  too  credulous,  in  our  days  there  is  too 
great  a  reaction  in  the  opposite  direction. 

Diagnosis. — There  is  not,  strictly  speaking,  any  part  of  the  body 
from  which  supplementary  menstrual  hsemorrhage  cannot  take  place. 
The  tegumentary  surfaces,  the  mucous  membranes  and  the  skin,  seem 
to  be  the  points  towards  which  the  menses  most  frequently  deviate. 
The  following  are  the  various  regions  in  which  this  phenomenon  has 
been  observed,  according  to  200  cases  collected  by  Puech  from  various 
authors : 


Scalp  ...... 

Auditory  canal             .... 

6 
6 

Eyes,  eyelids,  lachrymal  caruuculai    . 

10 

Nasal  epistaxis            .... 

18 

Cheeks             ..... 

3 

Dental  alveoli              .... 

10 

Salivary  glands,  or  buccal  mucous  membrane 

4 

Hsemoptysis   ..... 

24 

Hsemateuiesis               .... 

32 

Breasts             ..... 

25 

Trunk,  axillae,  back,  thoracic  parietcs 

10 

Umbilicus       ..... 

5 

Hsematuria     ..... 

8 

Intestine,  haemorrhoids 

10 

Hands  and  fingers      .... 

7 

Lower  limbs  ...... 

13 

Various  seats,  wounds,  ulcers,  exutories 

8 

The  above  table  shows  that,  whilst  these  haemorrhages  may  be  pro- 
duced anywhere,  they  show  a  predeliction  for  certain  localities.  For 
instance,  the  mucous  membrane  of  the  stomach,  the  breasts,  the 
mucous  membrane  of  the  bronchi  and  of  the  nose.  They  may  even 
take  place  from  the  roots  of  the  nails.  At  other  times  they  are  dis- 
charged from  varicose  veins,  from  recent  or  old  wounds,  or  from  ulcers 
which  resist  cicatrisation  in  spite  of  all  topical  applications.  I  have 
seen  them  take  place  from  the  vagina  and  internal  surface  of  the  vulva. 
At  other  times  they  are  produced  from  various  parts  of  the  body, 
either  simultaneously  or  separately  and  alternatively.  Pinel  has 
related  a  case  of  this  kind,  and  Gendrin  another,  to  which  I  shall 

'  Torthe  (Louis)  relates  a  case  he  saw  at  the  Hopital  Saint-Antoine  of  'pur- 
2)ura  hcemorrhagica  replacing  menstrual  hasmorrhage.  He  has  collected  nine 
cases  from  different  authors  showing  that  subcutaneous  sanguineous  extravasa- 
tions, ecchymoses,  and  petechia;  resembling  pui-pura,  sometimes  with  sometimes 
without  external  haemon-hage,  constitute  a  well-marked  form  of  menstrual 
deviation  {D'une  forme  rare  de  deviation  menstruelle.  Theses  de  Paris,  1877, 
No.  496). 

-  Senator  (Berlin  Klin.  Wochetisch.,  16  Dec,  1872,  No.  57)  mentions  four 
cases  of  women  in  whom  menstruation  was  iiTcgular,  and  who  suffered  periodi- 
cally every  month  from  an  attack  of  jaundice,  which  ceased  on  the  i-eappearance 
of  the  catamenia.  Fasbender  {Id.,  Ibid.,  April  20  and  -lune  1,  1875)  mentions 
two  other  cases  ;  the  menses  were  not  suppressed,  but  only  diminished. 


294  UTERINE    DISEASES    IN    DETAIL 

afterwards  refer.  Jacqueraier  and  Lissner  have  observed  fluctuating 
sanguineous  tumours  developed  periodically  at  the  surface  of  the 
thighs.  I  have  myself  observed  a  case  of  this  kind.^  This^supple- 
mentary  menstrual  hsemorrhage  occurs  always  from  the  mucous  mem- 
brane and  the  skin,  more  frequently  from  the  former,  because  it  is 
more  vascular,  and  because  the  epithelium  offers  less  resistance  than 
the  skin.  Although  the  hsemorrhage  is  produced  periodically,  the 
blood  is  not  always  evacuated  at  every  menstruation ;  it  may  accumu- 
late in  a  hollow  organ,  to  be  discharged  at  a  later  period.  I  knew  a 
maiden  lady  in  whom  for  a  long  time  supplementary  hsemorrhage  took 
place  into  the  stomach;  but  the  blood  often  remained  for  several 
months  before  being  ejected.  At  every  monthly  period  there  occurred 
very  characteristic  critical  phenomena  with  serious  disorders  of  the 
digestion.  After  some  months  these  disorders  acquired  greater  inten- 
sity, and  it  was  necessary  to  have  recourse  to  bleeding  to  put  a  stop  to 
the  spasm  and  to  provoke  vomiting.  In  the  matter  vomited  there  were 
various  layers,  evidently  superimposed,  from  the  purest  blood,  to  older, 
denser  clots,  some  decomposed  and  in  a  state  analogous  to  putrefac- 
tion. It  was  impossible  to  doubt  that  these  various  layers  were  the 
result  of  former  successive  hsemorrhages  produced  at  epochs  corres- 
ponding to  the  monthly  periods. 

The  predisposing  causes,  general  or  local,  are  very  obscure.  The 
circumstances  under  which  these  hsemorrhages  occur  vary  in  each 
woman,  and  yet  when  we  examine  authenticated  cases  they  have 
certain  symptoms  in  common.  As  a  rule  the  women  so  affected  have 
an  extremely  sensitive  nervous  system ;  others  are  hysterical.  The  age 
at  which  these  phenomena  occur  varies  :  they  are  generally  noticed 
soon  after  puberty,  or  at  the  approach  of  the  menopause.  Tueffard^ 
relates  a  very  uncommon  case,  in  which  the  hsemorrhage  appeared  for 
the  first  time  at  fifty-six,  six  years  after  the  menopause;  it  occurred 
regularly  every  month  by  the  breasts,  the  discharge  of  blood  lasting 
eight  days,  accompanied  by  the  general  phenomena  of  menstruation, 
and  lasting  for  a  year  up  to  the  time  when  the  case  was  published. 

As  a  rule  the  uterus  is  healthy ;  sometimes,  however,  it  is  more  or 
less  deranged.  Puech  has  met  with  menstrual  deviation  eleven  times 
in  women  in  whom  the  genital  canals  were  closed  congenitally  or 
accidentally ;  and  forty-two  times  in  women  having  a  fcetal  uterus  or 
congenital  absence  of  this  organ,^  a  new  proof  of  the  importance  of  the 
ovary  in  producing  menstruation. 

The  hsemorrhage  generally  occurs  after  sudden  suppression  of  the 
catamenia,  produced  by  a  violent  moral  emotion  or  by  some  strong 
physical  impression,  such  as  would  be   produced,  for   example,  by 

^  Puech,  Memoire  sur  les  Atresies  des  voies  genitales  de  lafemme. 

2  Union  medicale,  30  Nov.,  1872. 

^  Brown  has  lately  published  a  case  of  supplementary  ejiistaxis  in  a  girl,  in 
whom  the  vagina  was  reduced  to  a  cul-de-sac  and  the  uterus  to  two  horns 
(American  Journal  of  Med.  Science,  p.  575,  1872).  I  have  also  found  com- 
plete absence  of  the  uterus  and  upper  half  of  the  vagina  in  a  girl  who  had 
supplementary  epistaxis  without  ever  having  menstruated ;  a  painful  swelling 
of  one  ovaiy  was  felt  every  month  through  the  rectum,  a  little  to  the  right. 


DEVIATION    OF   THE    MENSES  295 

sudden  immersion  in  cold  water.  At  other  times  the  menses  are  only 
retarded  or  difficult,  when  after  an  insignificant  accidental  cause,  or 
even  without  apparent  cause,  there  occurs  at  the  time  when  the  cata- 
menia  ought  to  appear  a  sanguineous  fluxion  towards  the  region  or 
organ  naturally  or  accidentally  predisposed  to  these  haemorrhages. 

Yarious  explanations  have  been  given  of  deviation  of  the  menses. 
Some  have  thought,  with  Bordeu,  Vigarous,  &c.,  that  this  phenomenon 
is  produced  by  an  effort  of  the  womb  in  virtue  of  the  active  influence 
which  this  organ  exercises  on  other  parts  of  the  body.  Others  have 
considered  it  as  independent  of  the  action  of  the  uterus,  believing  it  to 
be  the  result  of  the  action  of  the  vis  mecUcatrix  provoking  this  pheno- 
menon in  order  to  replace  that  which  is  wanting,  and  to  which  the 
economy  is  already  accustomed.  Others  again  have  invoked  the  theory 
of  metastasis  to  explain  the  fact;  whilst  some  deny  all  connection 
between  menstruation  and  these  haemorrhages,  which  they  believe  to  be 
simply  congestive.  Scanzoni^  has  revived  an  explanation  of  this 
phenomenon  which  we  can  only  partially  accept.  These  haemorrhages, 
he  says,  having  their  seat  in  organs  independent  of  those  of  generation, 
are  always  occasioned  by  a  predisposition  resulting  from  an  anomaly 
of  structure  of  these  organs — an  anomaly  consisting  principally  in  an 
unusual  thinness  and  great  fragility  of  the  vessels.  Under  the  in- 
fluence of  the  general  vascular  excitement  manifested  in  the  majority  of 
women  at  the  monthly  period,  the  blood  makes  a  passage  for  itself 
externally  by  the  parts  in  which  the  abnormal  weakness  of  the  vessels 
offers  least  resistance.^  The  haemorrhage  which  results  acts  on  the 
genital  organs  in  the  way  of  revulsive  bloodletting.  If  it  is  abundant 
enough  to  put  a  complete  stop  to  uterine  congestion  there  will  be  no 
discharge  from  the  womb ;  if,  on  the  contrary,  it  is  scanty  the  supple- 
mentary haemorrhage  may  be  accompanied  by  a  shght  oozing  of  blood 
from  the  genital  organs. 

The  connection  of  these  haemorrhages  wdth  menstruation  cannot  be 
denied;  but  we  cannot  be  satisfied  with  the  explanation  of  a  so-called 
metastasis  of  blood  to  another  organ,  in  the  way  the  ancients  under- 
stood it,  and  which  the  figurative  expression  of  deviated  menstnmtion 
would  imply  if  taken  literally.  Is  it  not  merely  a  phenome- 
non of  reflex  action,  in  consequence  of  which  the  fluxionary  movement, 
finding  an  obstacle  in  the  uterus,  terminates  in  another  organ  and 
produces  an  abnormal  haemorrhage  ?  The  predisposition  of  the  organ, 
its  relatively  inferior  power  of  resistance  to  morbid  attacks,  would 
determine  the  question  of  locality.'^ 

The  influence  exercised ^  by  supplementary  menstruation  on  uterine 
menstruation  varies  according  to  the  date  of  the  amenorrhcea,  andaccord- 

»  Op.  cit.,  p.  319. 

^  There  is  something  true,  as  regards  the  seat  of  deviated  menstruation,  in 
the  clioicc  of  the  phace  oJTcring  least  resistance  ;  only  wc  must  not  ho  content 
with  the  admission  that  these  hacmorrhagiparous  organs  are  places  offering  least 
vascular  resistance,  they  must  rather  he  regarded  as  tissues  or  organs  oJVering 
least  resistance  to  any  morbid  influence  in  general. 

'  Lorey  adopts  this  pathogeny  (Des  vomisscments  de  sanr/  supplementaire, 
&c.     Theses  de  Paris,  1875). 


296  UTERINE    DISEASES    IN   DETAIL 

ing  to  the  existence  or  absence  of  fluxion  towards  the  uterus.  If  the 
amenorrhoea  is  recent  and  is  produced  by  a  sudden  suppression, 
Scanzoni^s  explanation  is  undoubtedly  correct ;  I  have  lately  seen  a 
girl  who  has  had  hemoptysis  under  such  circumstances;  in  such  a 
case  the  catamenia  may  return  the  following  month;  the  fluxion 
towards  the  lungs  is  not  of  sufficiently  long  standing  to  have  taken 
root  there,  nor  has  the  uterine  fluxion  been  so  completely  mobilised 
as  to  be  irremediably  deviated.  If,  however,  the  amenorrhcea  has 
lasted  long,  the  conditions  are  reversed ;  the  uterus  is  not  only  not 
congested,  the  fluxion  is  not  even  directed  towards  it ;  the  abundance 
or  scantiness  of  the  supplementary  hsemorrhage  will  have  very  little 
influence  on  the  absence  or  presence  of  uterine  hsemorrhage.  On  the 
other  hand,  of  however  old  a  date  the  amenorrhcea  may  be,  if  there  is 
periodical  fluxion  towards  the  uterus  and  congestion  of  that  organ, 
and  especially  if  the  functional  disorder  depends  on  defective  evacua- 
tion, or  derangement  in  the  physiological  manifestation  of  the  third 
element  of  this  function,  the  menstrual  haemorrhage  may  reappear  in 
spite  of  the  supplementary  haemorrhage. 

It  seems  as  if  other  excretions  may  be  supplementary  to  menstrual 
haemorrhage,  e.g.  hypersecretion  of  saliva,  sweat,  urine,  intestinal 
mucus,  diarrhoea,  pus  from  ulcers,  bile  causing  jaundice,  &c.  This 
appears  less  incredible  to  us  than  to  Nonat^  when  we  remember  that 
diarrhoea  often  precedes  menstruation,  whilst  leucorrhoea  replaces  it  in 
chlorotic  patients  suffering  from  amenorrhoea. 

Apart  from  these  theories,  we  must  find  out  whether  there  is  the 
same  connection  between  ovulation  or  spontaneous  dehiscence  and  the 
supplementary  haemorrhage  known  as  deviated  menstruation  that  there 
is  between  periodical  dehiscence  and  the  concomitant  uterine  haemor- 
rhage, especially  if  the  hseraorrhage,  whatever  may  be  its  seat,  occurs 
simultaneously  with  ovulation.  Light  has  been  thrown  on  this 
question  by  the  interesting  researches  of  Puech.^  A  very  interesting 
autopsy  showed  that  the  formation  of  the  corpora  lutea,  and  especi- 
ally the  recent  rupture  of  a  Graafian  vesicle  may  coincide  with  each 
supplementary  haemorrhage.  It  has  also  been  proved  that  pregnancy 
may  occur  in  patients  affected  with  deviation  of  the  menses. 

The  medical  journal  of  Montpelher^  relates  the  case  of  a  woman 
who  had  deviation  of  the  menses,  the  discharge  taking  place  through 
a  fistula  at  the  right  side  of  the  chest :  pregnancy  occurred  putting  a 
stop  to  this  discharge,  and  after  delivery  menstruation  took  place 
normally. 

Pauli  *  knew  a  girl  of  seventeen  in  whom  menstruation  was  replaced 
for  eighteen  months  by  bleeding  of  the  nose.  After  her  confinement 
menstruation  reappeared  regularly. 

A  woman  of  thirty,  of  delicate  constitution,  married  for  five  years 
■without  having  children,  menstruated  regularly  to  the  age  of  twenty- 

»  Op.  cit.,  p.  587. 

*  Academie  des  sciences.  Seance  du  13,  avril,  186.3. 
^  Journ.  de  med.  de  Montpellier,  2'  serie,  t.  v,  p.  212. 
■*  Gazette  viedicale,  1839,  p.  636. 


DEVIATION   OF   THE    MENSES  297 

six.  At  that  time  menstruation  ceased^  and  the  woman  believed  her- 
self to  be  pregnant.  A  few  weeks  afterwards  a  tumour  was  formed 
in  the  left  hypochondriac  region,  which  suppurated,  burst,  and  was 
converted  into  a  large  ulcer  fifteen  centimetres  square,  from  which  a 
certain  quantity  of  blood  was  discharged  regularly  every  three  or  four 
weeks.  The  internal  administration  of  emmenagogues,  and  the  appli- 
cation of  leeches  were  continued  for  some  years  without  success.  The 
woman  at  last  became  pregnant ;  the  discharge  of  blood  from  the 
ulcer  ceased,  the  wound  cicatrised,  and  all  passed  off  well.  Two 
months  after  delivery  normal  menstruation  recommenced  and  has 
continued  regularly  for  five  years.^ 

In  other  cases  which  we  have  to  relate  pregnancy  occurred  in  iden- 
tical conditions,  but  was  not  followed  by  similar  good  results.  Preg- 
nancy and  lactation,  it  is  true,  suspended  the  deviation,  but  only  tem- 
porarily, the  supplementary  hsemorrhage  reappearing  after  delivery  or 
after  lactation. — Catherine  Vincent,  who  menstruated  at  nine  years,  had 
her  monthly  periods  regularly  during  eight  days  of  every  month.  She 
was  hysterical,  and  when  annoyed  the  catamenia  were  accompanied  by 
the  oozing  of  a  sero-sanguineous  discharge  from  the  left  breast  and  axilla. 
She  became  pregnant  and  was  delivered  at  the  seventh  month.  When 
menstruation  was  re-established  the  deviation  also  reappeared,  and 
besides  taking  place  from  the  parts  above-mentioned,  it  occurred  also 
from  the  skin  of  the  left  loin,  from  the  back,  the  epigastrium,  the  left 
thigh,  &c.^ — A  woman  of  weak  constitution  had  after  her  first  confine- 
ment a  suppression  for  five  months,  then  the  catamenia  were  scanty 
for  five  or  six  months.  At  that  time  she  had  a  considerable  vomiting 
of  blood,  which  was  repeated  at  her  monthly  periods.  Under  these 
conditions  she  became  pregnant;  after  delivery  epistaxis  occurred 
periodically,  then  hematemesis.^ — A  woman  who  had  never  menstruated 
except  by  hematemesis  became  pregnant;  she  had  a  good  confinement, 
and  suckled  her  child  for  some  months.  On  being  obliged  to  give  up 
nursing  the  hematemesis  returned.  Afterwards  she  became  dropsical, 
and  died  at  the  end  of  six  months.* — A  woman  of  thirty-one  had  a 
sudden  suppression  owing  to  a  great  fright  she  had  experienced  at  her 
monthly  period.  The  following  month  the  catamenia  hardly  appeared, 
but  there  was  expectoration  of  blood,  which  stopped  spontaneously  at 
the  end  of  four  days.  From  that  time  a  more  or  less  abundant  dis- 
charge of  blood  occurred  every  month  by  the  lungs.  During  her 
pregnancies  menstruation  and  hemoptysis  both  ceased.  After  delivery, 
and  even  during  lactation,  the  hemoptysis  returned.  Her  health,  how- 
ever, was  in  no  way  affected.^ — Brierre  de  Boismont  tells  of  a  woman 
who  had  deviation  of  the  menses  during  her  whole  life  in  spite  of  a 
good  confinement. — Molinetti  knew  a  woman  of  great  beauty  who,  till 
the  age  of  fifty,  had  vomiting  of  blood  every  month  in  place  of  mcn- 

'  Gazette  medicale,  1843,  p.  532. — Obs.  o£  Dr.  Scliwabo  of  Weimar. 
^  Bulletin  de  la  Societe  royale  de  mcdecine. — Obs.  of  Dr.  Bonfils. 
^  Gendrin,  Traitr.  i^thilosophique  de  mcdecine  i^Tutique,  t.  ii,  p.  (55. 
■•  Journal  de  medecine,   1757,  t.  vii,  p.  384. — Obs.  by  Henry,  Surgeon  at 
Auxerre. 

•  Hoft'mann,  t.  ii,  p.  207. 


298  UTEPJNE  DISEASES    IN   DETAIL 

struation.  This  did  not  prevent  her  from  having  several  children.^ — 
A  woman  of  twenty-four,  who  had  never  menstruated,  was  subject  from 
the  age  of  fifteen  to  monthly  epistaxis.  She  became  pregnant,  when 
the  epistaxis  disappeared,  to  return,  however,  with  its  previous  regu- 
larity six  weeks  after  her  confinement.^ 

We  see,  therefore,  that,  except  in  cases  of  atresia  or  serious  disorder 
of  the  uterus,  deviation  of  the  menses  does  not  imply  sterility  ;  unless 
there  be  serious  derangement  of  the  economy  ovulation  continues  to 
take  place,  and  ruptitre  of  the  Graafian  vesicle  coincides  loitTi  the 
period  of  the  deviation.  Pregnancy  is  therefore  possible  and  has  been 
observed :  it  suspends  the  deviation,  which,  however,  reappears  after 
delivery  or  lactation.  Deviation  of  the  menses  depends  on  the  san- 
guineous fluxion  being  turned  from  the  uterus  by  some  cause  to 
another  organ  predisposed,  anatomically,  physiologically  or  pathologi- 
cally to  become  ^'d  pars  recipiens  of  this  fluxion.  The  recurrence  and 
the  periodicity  of  the  phenomenon  depend  on  the  same  causes  of  vital 
habit  which  kept  up  the  periodicity  of  the  uterine  fluxion  in  its  normal 
type. 

Treatment. — Although  compatible  with  health,  and  sometimes  lasting 
from  puberty  to  the  menopause,  deviation  of  the  menses  is  nevertheless 
a  pathological  process ;  it  is  even  a  serious  condition,  as  it  has  fre- 
quently caused  death.  It  is  more  than  a  functional  disorder,  it  is  an 
essentially  morbid  state.  It  is  useless  to  say  that  it  is  a  beneficent 
effort  of  the  vis  medicatrix ;  it  is  not  the  less  true  that  the  hgemorrhage 
takes  place  by  organs  whose  structure  is  not  physiologically  suited  for 
its  production,  and  that  it  is  provoked  and  kept  up  by  a  special  morbid 
condition.  It  is  true  that  the  economy  becomes  habituated  to  such  a 
state,  and  tolerance  may  be  established,  nevertheless  the  health  is  not 
perfect  till  the  supplementary  hsemorrhage  is  replaced  by  normal  men- 
struation. The  prognosis  varies  according  to  several  circumstances 
connected  with  the  production  of  the  hsemorrhages,  their  seat,  &c.  It 
is  only  serious  when  women  who  are  already  debiHtated  become  more 
so  by  the  prolongation  and  abundance  of  this  loss.  Death,  as  I  have 
said,  may  result,  and  one  of  the  most  curious  examples  of  this  termi- 
nation is  that  published  by  "Fricker  de  Horb,^  in  which  a  third  attack 
of  supplementary  nasal  epistaxis  was  followed  by  death.  It  is  unneces- 
sary to  say  that  when  hsemorrhage  occurs  in  important  organs  the 
danger  is  increased. 

Lastly,  considered  in  themselves,  and  independently  of  the  organs 
in  which  they  are  locahsed,  supplementary  hasmorrhages  are  always  a 
troublesome  accident.  Except  in  cases  of  atresia,  when  they  really 
prove  beneficial  by  obviating  uterine  distension,  they  produce  great 
inconvenience  to  the  patient ;  they  always  indicate  debility  ;  they  are 
extremely  difficult  to  cure;  they  recur  with  extreme  facility,  and  as 

1  Eelated  by  Berger,  Physioloyie,  chap,  xx,  p.  252. 

2  Otto  Obersaeur,  Virchow's  Archiv,  1872,  vol.  xlv,  part  3. 

3  Medecin.  Correspondenz-JBlatt,  1844,  p.  510. — Dunlap  {New  YorJc  Journ. 
of  Medicine,  May,  1856),  bajmorrbage  from  the  gums  ;  after  cupping  with  the 
scarificator  htemorrhage  ensued  and  carried  off  the  patient, 


DEVIATION   OF    THE    MENSES  299 

they  may  change  their  seat  or  threaten  an  important  organ,  they 
ought  to  have  the  serious  consideration  of  the  physician.  Cases  are 
on  record  which  have  lasted  during  the  whole  of  menstrual  life,  in 
spite  of  the  most  suitable  treatment.  De  Mynck  and  Kluyskens^ 
have  related  a  case  in  which  supplementary  haemorrhage  from  the 
breast,  established  at  forty,  terminated  at  fifty-eight  in  a  cancer. 

Treatment  should  be  directed :  1st,  to  the  amenorrhcea,  by  means 
previously  described;  2nd,  to  the  supplementary  haemorrhage,  the 
abundance  and  seat  of  which  may  indicate  various  means  in  addition  to 
haemostatics,  according  to  the  speciality  of  the  case.  Nothing  seems 
simpler  than  these  indications,  and  yet  the  result  is  very  uncertain. 

The  treatment  of  amenorrhcea  in  these  cases  consists  principally  in 
strengthening  the  constitution  and  in  drawing  to  the  uterus  the 
liaemorrhagic  molimen  produced  in  other  organs. 

In  order  to  fulfil  the  first  indication,  besides  having  recourse  to 
therapeutical  means,  great  attention  should  be  paid  to  hygiene.  In 
addition  to  a  generous  diet,  exercise  ought  to  be  prescribed ;  if  the 
patient  is  too  weak  to  walk  she  ought  to  drive.  Tonics  should  be 
given,  and  the  best  of  these  are  quinine  and  iron. 

To  fulfil  the  second  indication,  to  determine  a  fluxionary  movement 
towards  the  uterus  sufficiently  strong  to  turn  aside  the  abnormal 
fluxion,  we  may  employ  irritating  topical  applications,  mustard,  sitz 
baths,  dry  cupping,  or  with  the  scarificator,  leeches  to  the  inner  and 
upper  parts  of  the  thighs,  or  one  or  two  leeches  to  the  cervix,  or 
better  still  dry  cupping  which  does  not  cause  loss  of  blood,  or, 
if  necessary,  intra-uterine  dry  cupping  as  advised  by  Simpson.  The 
time  chosen  for  beginning  this  treatment  should  be  one  or  two  days 
before  the  monthly  period,  and  it  should  be  continued  the  whole  time 
it  lasts,  till  the  phenomena  of  abnormal  fluxion  have  completely 
disappeared. 

The  treatment  of  supplementary  hcemorrhages  is  less  important, 
except  when  these  discharges  endanger  life  by  their  intensity.  In 
such  cases  we  must  have  recourse  to  the  most  powerful  haemostatics, 
and  to  the  various  means  employed  in  the  general  treatment  of 
haemorrhages.  We  must,  however,  beware  of  trying  to  subdue  these 
abnormal  haemorrhages  energetically  before  having  re-established 
normal  menstruation :  we  should  run  the  risk  of  producing  them  on 
another  and  more  important  organ.  Forestus"  and  Chauflfe^  relate 
cases  of  mental  derangement  and  fatal  cerebral  apoplexy  occurring  as 
the  result  of  such  inopportune  treatment. 

'  Gazette  ined.  de  Paris,  1844,  p.  595. 
^  De  cerebri  morho,  obs.  24. 

■^  Des  accidents  et  des  maladies  qui  survlenncnt  a  la  cessation  de  la  mens- 
truation.    Theses  do  Paris,  an  x. 


300  UTEIMNE    DISEASES    IN    DETAIL 


Dysmenorrhcea 

Dysmenorrhoea^  according  to  its  etymology,  is  difficult  menstruation. 
This  disease  includes  sluggishness  and  difficulty  attending  the  cata- 
menial  discharge  ;  irregular  menstruation  ;  pains,  often  very  violent, 
usually  preceding  the  sanguineous  flow,  sometimes  accompanying  it ; 
menstrual  evacuation  in  certain  cases  nil,  in  others  insufficient,  some- 
times putting  a  stop  to  the  pain  on  its  first  appearance,  but  some- 
times occurring  without  any  cessation  of  the  pain,  and  occasionally 
acquiring  an  intensity  which  amounts  to  metrorrhagia. 

Diagnosis. — Aran  ^  has  given  a  very  exact  description  of  dys- 
menorrhoea  and  of  the  distinctive  features  of  this  pathological 
condition.  "The  menses  may  be  delayed  in  many  women  without 
affording  cause  for  anxiety.  Nothing  but  disorder  of  the  general 
health  or  abnormal  phenomena  manifested  in  the  genital  economy  need 
direct  the  attention  to  what  otherwise  is  merely  an  anomaly  of 
menstruation.  In  women  suffering  from  chlorosis  or  from  any  serious 
disease  of  a  debilitating  nature,  the  menses  are  delayed  more  and 
more,  till  at  last  they  cease  altogether  or  only  recur  at  long  and 
irregular  intervals;  unless  an  effort  is  made  by  the  organism  to 
re-establish  them,  the  physician  ought  to  confine  his  attention  to  the 
chlorosis  and  to  the  debilitating  pathological  condition ;  delay  in  the 
appearance  of  the  menses  is  only  a  cry  of  alarm,  a  signal  of  distress 
from  the  economy.  They  may,  however,  be  delayed  amid  symptoms 
which  betray  an  energetic  effort  for  their  re-establishment.  Very  often 
these  symptoms  do  not  differ  much  from  those  which  coincide  with  the 
sudden  or  prolonged  suppression  of  the  catamenia ;  but,  limited  to  the 
genital  economy,  or  at  least  affecting  it  principally,  they  have  with 
reason  received  the  name  of  dysmenorrhcea.  The  symptoms  of 
dysmenorrhcea,  without  being  completely  similar  in  all  cases,  yet  have 
a  common  basis,  viz.  sluggishness,  the  difficulty  with  which  the  dis- 
charge is  established  each  time,  its  irregularity ;  the  presence  of  pain 
in  the  uterine  system,  and  often  in  other  of  the  organic  systems  for 
some  hours  or  days  before  its  appearance,  pain  which  increases  till  the 
catamenia  appear." 

It  is  easy  to  understand  that  dysmenorrhcea  is  principally  met  with 
in  girls,  or  in  women  who  have  never  been  pregnant.  It  is  not 
enough  to  recognise  its  existence  in  the  preceding  symptoms ;  it  is 
important  further  to  distinguish  between  symptomatic  and  idiopathic 
dysmenorrhcea.  In  one  sense  all  dysmenorrhcea  is  symptomatic  of  a 
morbid  condition;  but  when  this  condition  is  not  produced  by  any 
persistent  organic  derangement,  and  may  disappear  under  the  influence 
of  a  modification  of  the  functions  of  innervation  or  of  the  vascular 
system,  the  dysmenorrhcea  is  called  idiopathic;  when,  on  the  contrary, 
it  is  caused  by  contraction  of  the  orifices  or  by  a  disorder  of  the 
mucous  membrane  requiring  the  intervention  of  the  surgeon,  it  is  called 
spnptomatic. 

1  Op.  cit.,  p.  300. 


DYSMENORRHCEA  30l 

Djsmenorrlioea  may  be  s?/mptomaiic  of  simple  neuralgia,  especially 
of  lumbo-sacral  neuralgia.  It  may  also  be  symptomatic  of  an  organic 
lesion  depending  on  a  nutritive  alteration  of  local  life,  a  fibrous 
tumour,  polypus,  hypertrophy,  or  the  localisation  of  a  diathetic  affec- 
tion such  as  cancer ;  but  these  lesions  are  complicated  with  menor- 
rhagia  and  metrorrhagia  more  frequently  than  with  dysmenorrhoea. 

It  may  also  be  symptomatic  of  the  formation  of  a  clot  in  the  uterine 
cavity ;  but  this  formation  infers  other  lesions,  such  as  coarctation  of 
the  cervical  orifice  or  dilatation  of  the  body  of  the  womb.  It  is  fre- 
quently symptomatic  of  uterine  congestion,  of  acute  or  chronic  uterine 
inflammation,  of  inflammation  of  the  appendages,  &c.  Oftener  still, 
it  is  symptomatic  of  anteflexion  or  retroflexion,  and  especially  of  torsion 
and  contraction  of  the  cervico -uterine  canal,  with  partial  retention  of 
the  menses,  and  of  the  monthly  exfoliation  followed  by  the  periodical 
expulsion  of  the  mucous  membrane  with  the  menstrual  blood ;  hence 
the  name  of  mechanical  dysmenorrhcea  and  of  membranous  dysmenor- 
rhoea to  distinguish  them  from  symptomatic  dysmenorrhoea. 

Idiopathic  dysmenorrhoea  is  not  connected  with  any  cause  foreign 
to  menstruation  itself.  It  is  a  functional  irregularity  affecting  one  or 
more  of  the  three  elements  (fluxion,  congestion,  evacuation)  of  the 
catamenial  act,  and  produced  by  a  deterioration  in  the  health  and 
oftener  in  the  local  life  of  the  organ,  the  nature  of  which  may  vary, 
allowing  of  the  existence  of  differences  in  the  essential  cause  of  dys- 
menorrhoea, and  consequently  in  the  indications  for  treatment.  With 
regard  to  this  nature,  all  physicians  recognise  a  nervous,  spasmodic, 
hysteriform  dysmenorrhoea,  and  a  sanguineous,  vascular,  congestive 
form.  The  first  depends  on  a  state  of  pain,  spasm,  or  neuralgia,  which 
has  led  to  its  being  called  catamenial  hysteralgia ;  the  second  depends 
principally  on  hypersemia  of  the  organ.  The  first  consists  specially  in 
a  derangement  of  the  mode  in  which  the  fluxion  takes  place  towards 
the  organ,  or  of  the  mode  in  which  the  uterus  is  accessory  to  the 
evacuation  of  the  fluid,  under  the  influence  of  a  derangement  of  in- 
nervation ;  the  second,  in  an  excess  of  congestion  or  an  alteration  in 
the  manner  in  which  it  is  produced,  either  that  it  is  limited  to  the 
uterus  or  that  it  is  extended  to  the  Pallopian  tubes  and  to  the  ovaries 
under  the  influence  of  a  derangement  of  the  circulation,  and  is  vitiated 
in  its  mode  of  termination,  even  to  the  extent  of  producing  hseraor- 
rhagic  centres  in  the  Fallopian  tube  or  in  the  ovary,  and  even 
hsematocele. 

1.  Idiopathic  Bt/smenorrhoea 

Differential  diagnosis. — Nervous  dysmenorrhcBa  is  characterised  by 
general  and  local  disorders  of  innervation.  Pain,  spasm,  neuralgia, 
developed  in  the  uterus,  in  the  uterine  system,  in  the  neighbouring 
organs,  or  even  in  the  whole  economy  during  menstruation,  may  equally 
play  the  part  of  essential  cause  of  the  disease,  either  separately,  suc- 
cessively or  simultaneously.  These  morbid  conditions  may  be  them- 
selves under  the  dependence  of  various  general  or  diathetic  affections. 
However  that  may  be,  one  of  these  elements,  pain,  spasm  or  neu- 


/ 


302  UTERINE    DISEASES    IN    DETAIL 

ralgia  may  characterise  this  kind  of  dysmenorrhcea  in  an  especial 
way. 

As  a  rule  the  symptoms  (discomfort,  dyspepsia,  cephalalgia,  more  or 
less  violent  lumbar  and  hypogastric  pain)  cease  as  soon  as  the  menses 
appear,  especially  when  the  discharge  is  abundant ;  if,  however,  it  only 
comes  by  drops  (stillicidium  uteri  of  Aetius,  tUerine  strangury,  as  con- 
trasted with  vesical  strangury)  they  may  persist  for  a  longer  or  shorter 
time,  and  be  the  indication  of  a  contraction  of  the  cervix  or  of  the  os 
internum  in  which  the  nervous  state  seems  specially  to  be  localised ; 
they  may  continue  till  the  expulsion  of  a  clot,  which  follows  the  incom- 
plete sanguinolent  or  sero-sanguinolent  discharge  permitted  by  the  im- 
perfect permeability  of  the  orifice,  or  which  is  accompanied  by  real 
menorrhagia,  and  announces  the  imminent  cessation  of  the  trouble  and 
soon  of  menstruation  itself.  These  symptoms  may  attain  an  extreme 
degree  of  intensity ;  I  have  seen  girls  shed  tears,  scream  with  pain, 
writhe  in  bed,  roll  on  the  ground.  The  violence  of  the  pains  may  even 
react  on  the  whole  economy,  causing  nausea,  vomiting,  hysterical  or 
epileptiform  symptoms,  &c. 

Congestive  dysmenorrhcea  is  characterised  by  the  symptoms  of  con- 
gestion itself ;  discomfort,  sense  of  pelvic  fulness  and  weight,  frequent 
micturition,  heat  and  smarting  in  passing  water,  tenesmus,  diarrhoea, 
swelling  of  the  breasts.  The  symptoms  may  increase  during  the  first 
few  hours  following  the  commencement  of  evacuation.  The  pain  may 
increase  so  as  to  assume  the  character  of  the  expulsive  pains  of  labour, 
shooting  down  the  groins  and  thighs,  increasing  at  intervals  and  being 
accompanied  by  swelling  of  the  hypogastrium,  which  cannot  tolerate 
the  touch  of  the  hand  or  the  contact  of  the  clothes.  At  this  period 
the  pains  may  attain  the  violence  and  assume  the  form  of  those  of 
nervous  dysmenorrhcea,  both  in  their  local  manifestation  and  in  their 
reaction  on  the  whole  economy.  Usually  all  these  phenomena,  the  pain 
especially,  disappear  in  proportion  as  the  flow  increases,  unless  the 
dysmenorrhcea  has  caused  congestion  of  the  uterus.  At  other  times 
patients  sufi'er  from  dull  pelvic  pain,  not  only  all  the  time  of  the  men- 
strual flow  but  also  for  some  days  after  it  has  stopped. 

It  is  the  congestive  form  that  is  related  to  what  Simpson^  called 
ovarian  dysjnenorrhma,  which  depends  on  the  excess  of  congestion 
which  causes  the  pain  affecting  the  ovary  rather  than  the  uterus. 
The  tension  and  sensitiveness  of  the  ovaries  are  especially  evident 
when  these  organs  are  displaced,  either  into  the  recto-vaginal  cul-de-sac 
of  the  peritoneum,  or  into  a  hernial  sac.~  It  is  often  met  with  in 
aneemic  women  as  the  result  of  defective  equilibrium,  of  unequal 
distribution  of  blood.  It  is  also  frequently  observed  in  prostitutes,  in 
i  whom  it  is  produced  b)?  venereal  excesses,  and  it  is  sometimes  met  with 
in  old  maids  and  in  young  widows  as  a  consequence  of  unsatisfied 
sexual  instinct. 

*  Simpson,  op.  cit.,  p.  411. 

'  In  a  case  related  by  Oldham  {Philosophical  Transactions),  in  which  the 
6vaiy  descended  by  the  inguinal  canal  into  the  labium,  this  organ  swelled  some! 
days  before  the  appearance  of  the  menses,  and  the  patient  suffered  greatly. 


DTSMENOREHGEA  303 

Treatment. — The  indications  differ  according  to  the  nature  of  the 
dysmenorrhcea. 

In  nervous  dysmenorrlma  the  two  elements  of  pain  and  spasm  are 
the  two  principal  sources  of  indications.  The  element  of  neuralgia  and 
the  neuralgic  form  assumed  by  the  pain  may  give  rise  to  a  third  order 
of  indications,  to  the  special  indications  of  neuralgia ;  these  may  exist 
apart  from  the  menstrual  period,  they  may  vary  according  to  the  locali- 
sation of  the  neuralgia  and  the  essential  cause  of  the  affection  which 
keeps  it  up  ;  frequently,  however,  the  same  medication  is  employed  with 
equally  good  results  in  cases  of  neuralgia,  properly  so  called,  and  of 
pain. 

Fain  is  subdued  by  narcotics,  and,  if  necessary,  by  anesthetics,  such 
as  the  various  preparations  of  opium,  morphia,  laudanum,  henbane, 
belladonna,  Indian  hemp,^  ether,  chloroform,  &c. 

To  prevent  dysmenorrhcea,  general  baths  for  an  hour  or  more  should 
be  [prescribed,  made  with  a  decoction  of  bran  or  gelatine,  and  re- 
peated daily  for  some  days  before  the  menses  are  expected ;  or  sitz- 
baths  with  vaginal  injections  of  a  decoction  of  poppy-heads,  or 
henbane  and  belladonna  leaves;  sedative  embrocations  of  camphorated 
chamomile  oil,  laudanum,  morphia,  &c.,  should  be  applied  to  the 
hypogastrium,  the  groins,  and  the  inner  surface  of  the  thighs,  and 
care  should  be  taken  to  keep  the  bowels  open  by  means  of  emollient 
or  laxative  enemata.  The  moment  that  the  catamenia  appear,  if  there 
is  dysmenorrhoeic  pain,  opium  or  morphia  should  be  given  ;  perhaps 
the  best  method  is  to  give  a  small  enema  of  decoction  of  marshmallow 
or  poppy-heads  with  from  10  to  20  drops  of  laudanum,  which  may 
be  repeated.  Bromide  of  potassium  in  doses  of  from  8  grains  to  5j 
in  the  day,  given  before,  during,  and  after  menstruation  sometimes 
produces  beneficial  effects.  Hot  linen,  antispasmodic  infusions,  baths 
of  bran  or  lime-tree  flowers  (Jx  in  a  bath)  taken  during  menstruation 
may  produce  a  sedative  effect.  Lastly,  if  the  pain  instead  of  yielding 
becomes  excessive,  inhalations  of  ether  or  chloroform  may  be  tried, 
as  advised  by  Bennet  and  Aran. 

Spasm  is  more  effectually  subdued  by  the  administration  of  anti- 
spasmodics given  alone  or  associated  with  the  sedatives  just  men- 
tioned. Orange-flower  water,  ether,  valerian,  castoreum,  musk, 
camphor,  assafoetida,  ammonia,  hydropathy,  have  often  put  a  stop 
to  the  most  violent  attacks  of  dysmenorrhcea.  After  having  used  baths 
and  narcotics  as  preventive  measures  in  the  various  forms  above  named, 
spasm  may  often  be  relieved  by  25  to  30  drops  of  the  following  anti- 
spasmodic mixture  :  Sulphuric  Ether,  Tinct.  Valerian.,  Tinct.  Castor., 
Tinct.  Op.,  aa  5J,  with  a  tablespoonful  of  distilled  orange-flower 
water  in  half  a  glass  of  eau  svcree,  to  be  taken  in  spoonfuls  every  five 
minutes ;    a  second  dose  may  be  given  in  an  hour  if  required.     I 

'  ^.     Lupulin,  gr.  3  ; 

Ext.  Cannabis  Ind.,  gr.  \. 

M.  ft.  pilula. 
Sig.     Take  two  pills  In  the  morning  and  tlirce  in  the  evening  as  soon  as  thd 
first  3ymptoms  appear  (Deljout,  Aran). 


304  UTERINE    DISEASES    IN    DETAIL 

have  little  confidence  in  musk  and  camphor^  but  if  the  above-named 
antispasmodics  do  not  succeed,  assafoetida  may  do  good  (1^  gr.  in  a 
pill  given  every  hour,  or  30  gr.  suspended  in  yolk  of  egg  in  3^  oz. 
of  decoction  of  poppy-heads  as  an  enema);  or  15  gr.  of  sesquicar- 
bonate  of  ammonia,  or  a  few  drops  of  ammonia  in  a  glass  of  water. 
Lastly,  cold  compresses  on  the  hypogastrium,  and  other  hydropathic 
applications  often  do  great  good  when  administered  with  caution. 

When  spasm  especially  affects  the  cervix,  and  it  has  been  ascer- 
tained, by  the  pain  which  the  sound  causes,  and  by  the  difficulty  of 
passing  it  through  the  internal  os,  that  this  orifice  is  probably  con- 
tracted, we  may  try  the  effect  of  applying  belladonna  to  the  cervix, 
or  we  may  inject  a  few  drops  of  a  solution  of  neutral  sulphate  of 
atropine  (1  in  100)  into  the  tissue;  or  douche  this  organ  with 
carbolic  acid  or  chloroform  spray  ;  or  subdue  the  spasm  by  using 
the  sound  every  day  or  every  other  day  shortly  bsfore  the  monthly 
period,  or  even  by  introducing  a  gutta-percha  sound  or  one  of 
Simpson^s  solid  pessaries  of  ivory  or  metal,  and  leaving  it  for  a  few 
hours.  This,  however,  ought  not  to  be  employed  unless  we  are 
sure  of  the  absence  of  any  inflammatory  element,  and  only  after 
having  tested  the  susceptibility  of  the  uterus  by  touch. 

In  congestive  di/smenorrlicea  there  are  two  different  sources  of  indi- 
cation :  an  excess  or  defect  of  strength,  hypersthenia,  or  asthenia, 
which,  although  opposite  in  character,  may  equally  cause  hypersemia. 

Hypersthenia,  by  increasing  the  intensity,  energy,  and  persistency 
of  fluxion,  gives  to  congestion  an  importance  which  exceeds  all 
physiological  bounds,  and  brings  about  all  the  conditions  of  acute 
uterine  congestion.  The  treatment  of  this  morbid  condition  does  not 
differ  from  that  of  congestion.  Asthenia,  implying  defective  fluxion  or 
inertia  of  the  uterus  in  excreting  the  menses,  indicates  the  use  of 
various  stimulants  of  the  uterine  system,  the  value  of  which  has 
already  been  discussed  in  the  treatment  of  amenorrhoea  :  attractions, 
emmenagogues,  cold  douches,  electricity,  kc,  or  even  the  momentary 
or  prolonged  introduction  of  the  sound  or  of  solid  stem  pessaries  into 
the  uterine  cavity. 

In  the  interval  between  the  monthly  periods  baths  of  bran  or  starch 
should  be  recommended,  and  especially  exercise,  living  in  the  country, 
travelling,  &c.  West^  and  Simpson,^  believing  that  dysmenorrhcea  is 
caused  by  a  rheumatic  or  gouty  diathesis,  recommend  the  use  of 
tincture  of  colchicum  associated  with  small  doses  of  laudanum  and 
antimonial  wine.  The  colchicum  is  to  be  continued  during  the 
whole  intercalary  period,  or  the  iodide  of  potassium  may  be  substi- 
tuted for  it.  A^ichy  water,  the  baths  of  Carlsbad  or  Wiesbaden,  and 
other  means  indicated  by  the  nature  of  the  affection  complete  the 
treatment. 

Lastly,  the  indications  vary  according  to  whether  we  are  consulted 
during  the  crisis  or  in  the  intervals.     In  the  first  case,  as  Simpson^ 


1  Op.  cit ,  p.  87. 
-  Op.  cit.,  p.  242. 
■'  Op.  cit.,  p.  234. 


DYSMENOERH(EA  305 

wisely  remarks,  the  treatment  is  simply  palliative,  our  aim  being  to 
mitigate  the  paroxysm  ;  in  the  second,  it  is  curative,  radical  or  pre- 
ventive, the  indication  being  to  destroy  the  obstacle  to  the  free 
evacuation  of  blood,  or  to  prevent  the  return  of  the  symptoms  by 
various  means,  according  as  the  dysmenorrhoea  is  nervous  or  conges- 
tive; not  only  by  therapeutical  means,  but  by  hygiene,  hydropathy, 
exercise  on  horseback  and  on  foot,  in  short,  by  every  means  that 
can  subdue  the  nervous  irritability,  or  diminish  the  tendt-ncy  to  con- 
gestion by  re-establishing  equilibrium  in  the  general  circulation. 

2.  Mechanical  djjsnienorrhcea 

This  malady,  which  Simpson^  describes  under  the  name  of  obstruc- 
tive dysraenorrhma,  and  which  some  German  authors  designate  as 
stenosis  of  the  cervix,  is  nothing  more  than  the  series  of  symptoms 
developed  by  the  energetic  and  painful  contractions  of  the  uterus  in  its 
endeavour  to  expel  the  product  of  menstruation  through  too  narrow  an 
orifice.  It  is  in  miniature  the  morbid  state  produced  by  complete 
retention. 

Diagnosis. — The  seat  of  contraction  may  be  at  the  external  os, 
throughout  the  cervico  uterine  canal,  or  at  the  internal  os;  but  usually 
it  is  at  the  external  os.  Mackintosh^  called  attention  to  this  subject 
in  1823,  and  in  1826  proposed  dilatation  by  bougies.  The  cause, 
which  is  always  organic,  is  a  congenital  malformation,  or  a  cicatrix 
following  upon  inflammation  and  ulceration  of  the  cervix,  laceration, 
or  inopportune  or  unskilful  cauterisations.  When  the  deformity  is 
congenital  it  is  designated  by  the  name  of  narrow  os;  when  accidental 
it  is  called  contracted  os.  The  malady  is  characterised  not  only  by  the 
violence  of  the  expulsive  pain,  uterine  tenesmus  and  muscular  contrac- 
tions of  the  womb,  but  by  the  difficulty  of  evacuation,  the  blood 
escaping  only  in  small  quantities  at  intervals,  sometimes  under  the 
form  of  narrow  elongated  clots  mixed  with  fibrinous  concretions.  The 
tumefaction  of  the  uterus  by  the  blood,  which  has  a  difticulty  in 
escaping,  causes  excessive  congestion  and  irritation  in  the  organ, 
which,  according  to  Eigby,^  is  sometimes  transraitttd  to  the  ovary, 
producing  pains  in  the  groin  and  even  causing  menorrhagia.  The 
examination  of  the  uterus  by  speculum,  and  the  introduction  of  a  very 
fine  sound,  enables  us  to  ascertain  the  reality  of  the  impediment. 
AYhen  the  contraction  is  at  the  internal  os  it  is  sometimes  necessary  to 
dilate  the  external  orifice  and  cervical  cavity  previously  with  sponge 
tents  in  order  to  make  sure  of  the  fact.  It  seldom  happens  that  the 
internal  os  is  narrow  when  the  external  one  is  so,  unless  the  narrow- 
ness of  the  former  is  more  marked  than  that  of  the  latter ;  for  the  im- 
pediment caused  by  the  latter  to  the  escape  of  the  blood  produces  an 
accumulation  of  this  fluid  in  the  uterine  cavity  situated  above,  and  so 
necessarily  leads  to  the  dilatation  of  the  internal  orifice.  The  narrow- 
ness of  the  OS  is  the  most  common  obstacle  to  menstrual  excretion.    It 

1  Op.  cit.,  p.  215. 

^  Practice  of  Physic,  4tli  edit.,  t.  ii,  pp.  436,  481.     London,  1836. 

^  Med.  Times,  25th  October,  1851. 

20 


806 


UTERINE    DISEASES    IN    DETAIL 


is  always  indicated  by  the  circular  form  of  this  orifice  (a  point  instead 
of  a  line) ,  so  much  so,  that  circular  form  and  narrowness  of  the  orifice 
are  almost  synonymous,  whilst  narrowness  of  the  os  and  dysmenorrhoea 
are  almost  invariably  associated.  If  menstruation  is  scanty  this 
narrowness  may  not  have  any  troublesome  consequences,  and  may 
even,  to  a  certain  point,  pass  unnoticed.  This  is  what  often  occurs  at 
the  commencement  of  sexual  life.  If,  however,  the  fluxionary  move- 
ment and  the  quantity  of  menstrual  blood  are  increased  by  the  develop- 
ment of  puberty  or  by  marriage,  the  blood  has  difficulty  in  escaping, 
and  clots  are  formed,  which  increase  the  difficulty.  Expulsive  pains 
are  developed ;  sometimes  uterine  cramps  are  associated  with  these 
pains.  DysmenorrhcEa  is  accompanied  by  retention,  and  assumes  the 
form  of  spasmodic  nervous  dysmenorrhoea.  By  dint  of  contracting  in 
order  to  expel  the  retained  blood,  by  constant  dilatation  from  this 
menstrual  retention,  the  uterus  is  in  a  continual  state  of  hypersemia, 
and  remains  congested.  The  dysmenorrhcea  takes  the  character  of 
congestive  dysmenorrhcea.  This  character  is  added  or  even  substituted 
for  those  of  retention  or  spasm.  The  congestion  cannot  long  remain 
in  the  parenchyma  with  pain,  contractions,  &c.,  without  producing 
inflammation  in  the  tissue  proper.  On  its  side  contact  with  the  retained 
blood  irritates  the  mucous  membrane,  and  soon  metritis  (parenchy- 
matous, congestive,  sometimes  hsemorrhagic)  and  endometritis  (leucor- 
rhceic,  granular,  &c.)  are  added  to  or  substituted  for  the  simple 
mechanical  dysmenorrhcea  which  was  present  at  the  outset. 


Fig.  219. 


Fig.  220. 


Fig.  221. 


Fig.  219. — Narrow  round  os  on  a  cervix  of  normal  conformation  already  con- 
gested. 

Fig.  220. — Narrow  os,  round  and  excentric,  on  a  cervix  of  normal  conformation 
more  strongly  congested. 

Fig.  221. — Narrow  os,  round  and  excentric,  on  a  cervix  of  normal  conformation, 
still  more  congested  than  the  others  and  inflamed. 


Such  is  the  course  which  the  malady  takes  in  married  women. 
Thenceforwards  symptoms  of  inflammation  are  added  to  those  of 
mechanical  dysmenorrhoea  caused  by  narrowness  of  the  os.  These 
symptoms  become  aggravated,  and  are  multiplied  and  complicated  day 
by  day.  Sterility,  which  is  equally  a  consequence  of  narrow  os,  is 
associated  with  the  other  symptoms,  and  helps  to  complete  the 
diagnosis. 


DYSMENORRHCEA 


307 


In  virgins  this  mechanical  dysmenorrhoea  may  cause  the  gradual 
diminution  of  the  menstrual  haemorrhage  till  it  ceases  almost  entirely, 
sometimes  completely,  when  atrophy  may  be  produced ;  but  this  is  rare. 


Fig.  222.  Fig.  223.  Fig.  224. 

Fig.  222. — Congenitally  narrow  os  on  projecting  cervix  (after  Sims). 

Fig.  223. — Narrow  os  on  a  congested  projecting  cervix. 

Fig.  224. — Narrow  os  on  an  inflamed  and  congested  projecting  cervix. 

In  married  women,  on  the  contrary,  the  phenomena  previously 
described  occur  invariably ;  whether  the  cervix  is  normal,  slightly 
conical,  or  very  conical  and  long,  it  gradually  increases  in  volume,  as 
seen  in  the  accompanying  figures.     Besides  increasing  in  size  it  becomes 


Fig.  225.  Fig.  226.  Fig.  227. 

Fig.  225. — Narrow  os  on  a  long  and  conical  cervix. 
Fig.  226. — Narrow  os  on  a  long,  conical  and  congested  cervix. 
Fig.  227. — Narrow  os  on  a  long,  conical,  congested  and  inflamed  cervix. 

dark  red  in  colour,  very  sensitive  and  painful  to  the  touch;  the 
orifice  becomes  slightly  enlarged,  sometimes  assuming  a  cup  form,  but 
still  remains  insufficient  for  excretion.  Therefore,  in  order  to  put  a 
stop  to  these  troubles  it  must  be  enlarged.  The  preceding  figures 
show  the  changes  which  mechanical  dysmenorrhoea  produces  in  the 
cervix,  whilst  the  figures  which  follow,  taken  from  plaster  casts,  show 
the  changes  produced  in  the  form  of  the  uterine  cavities.  When  the 
narrowness  of  the  os  is  sufficient  to  cause  retention  of  the  menses  or 
of  mucus,  the  capacity  of  the  uterine  cavity  may  be  increased;  and  even 


308 


UTERINE    DISEASES    IN    DETAIL 


the  orifices  of  the  Fallopian  tubes  may  become  sufficiently  dilated  to 
allow  of  the  entrance  of  the  sound. 


Fig.  228.  Fig.  229. 

Fig  228. — Cast  of  the  cavities  of  a  normal  uterus  in  a  virgin  of  seventeen. 
Fig.  229. — Cast  of  the  uterine  cavities  in  a  nullipara  of  twenty-five  or  thirty ; 

marked  constriction  and  elongation  of  the  isthmus  ;  enlargement  of  the 

cervical  cavity  ;  constriction  of  the  external  orifice. 


Fig.  230.  Fig.  231. 

Fig.  230. — Cast  of  the  uterine  cavities  in  a  nullipara  of  forty-two  ;  marked 
constriction  of  the  os  externum.  Its  form  is  the  same  as  that  of  the 
virgin  uterus,  hut  the  horns  are  larger,  the  isthmus  is  dilated,  and  owing 
to  the  constriction  d,  the  upper  segment  of  the  hody  and  the  cervical 
cavity  are  more  developed. 

Fig.  231. — Cast  of  the  uterine  cavities  in  a  multipara  of  thirty-five  ;  constric- 
tion and  torsion  of  the  isthmus  ;  permanent  lateral  deviation  of  the  body 
on  the  cervix  ;  c,  well-marked  enlargement  of  the  body. 


DYSMENORRHCEA  309 

Torsion  of  the  isthmus  (Fig.  231)  which,  Kke  other  flexions,  may 
either  be  primitive  or  occur  after  childbirth,  is  also  a  cause  of  mechan- 
ical dysmenorrhoea,  to  which  I  shall  have  occasion  to  refer  when 
speaking  of  flexions. 

Treatment. — It  is  important  to  treat  mechanical  dysmenorrhoea 
because  the  pains  that  it  produces  are  intense  and  have  no  tendency 
to  disappear  naturally,  because  sterility  is  the  invariable  consequence, 
and  the  secondary  effects  disorder  the  health  seriously.  The  treatment 
is  mechanical,  like  the  cause  of  the  disease,  and  at  the  same  time  that 
it  cures  the  dysmenorrhoea  it  also  removes  the  inflammation  and  con- 
gestion which  result,  as  well  as  the  leucorrhoea  and  other  disorders  of 
the  mucous  membrane  which  owe  their  existence  to  the  same  cause, 
and  very  often  it  is  followed  by  pregnancy.  It  is  analogous  to  that  em- 
ployed in  constrictions  of  other  organs,  consisting  in  dilatation  (rapid 
or  gradual),  incision,  or  autoplasty  of  a  new  orifice. 

1.  Dilatation. — Rapid  dilatation  by  means  of  intra-uterine  forceps 
or  speculum,  the  branches  of  which  are  introduced  closed  into  the 
cervix  and  then  opened  quickly,  has  the  disadvantage  of  causing 
lacerations.  It  is  only  admissible  in  cases  of  constriction  caused  by 
muscular  contraction  of  the  sphincter,  with  more  than  a  sufficiency  of 
mucous  membrane  externally  as  well  as  internally,  that  is,  in  spite  of 
EUinger^s  ^  assertion,  in  the  minority  of  cases.  Gradual  dilatation  is 
preferable.  Of  course,  before  using  a  dilator  we  must  be  sure  that 
the  dysmenorrhoea,  and  the  constriction  which  causes  it,  are  not  con- 
nected with  some  other  morbid  condition.  Among  complications 
which  contra-indicate  the  use  of  dilatation  I  may  mention  inflamma- 
tion especially.  If  there  be  any  uterine,  peri-uterine,  or  ovarian 
phlegmasia  it  should  be  subdued  by  leeching  and  the  use  of  anti- 
phle^istics ;  for  in  siich  cases  there  would  be  as  great  a  danger  in 
dilating  as  in  cauterising  the  cervix.  Mackintosh^  used  flexible 
bougies  or  metallic  rods  of  gradually  increasing  "volume ;  Rigby  a 
dilator  with  steel  blades,  which  were  opened  and  left  for  some  time  in 
the  cervix;  Eaynaud,  of  Montauban,^  conical  wax  bougies,  by  means 
of  which  he  obtained  pregnancy  in  two  very  interesting  cases  of 
dysmenorrhoea  and  sterility ;  Simpson  metalHc  stems  of  gradually 
increasing  size,  supported  by  an  oval  bulb,  which  rests  on  the  poste- 
rior wall  of  the  vagina  and  keeps  the  instrument  in  place  without 
causing  fatigue.  These  stems  are  left  a  longer  or  shorter  time, 
according  to  the  irritability  of  the  uterus  and  the  sensitiveness  of  the 
patient.  As  a  rule,  she  ought  to  remain  in  bed ;  if  she  is  sensitive 
the  instrument  is  only  left  for  one  or  two  hours.  It  is  applied  again 
the  next  day  or  the  following  one;  the  stem  is  changed  for  a  larger 
one  as  soon  as  the  canal  is  sufficiently  dilated  to  allow  of  its  entrance. 
If  the  patient  tolerates  the  dilatation  well,  the  first  stem  may  be  left 

'  Arcliivfilr  Chjnaelcol.,  Bd.  v,  Heft.  2.     Berlin. 

^  Out  of  twenty-seven  women  he  cured  twenty-four,  and  eleven  of  the 
twenty-four  had  children. 

'  Jobert  de  Laniballe's  "  Report  to  the  Academy  of  Medicine  on  llaynaud's 
Paper,"  Bulletin  de  V Academic,  25  June,  1850. 


310 


UTERINE  DISEASES  IN  DETAIL 


Fig.  232. 

Simpson's  intra- 
uterine stem. 


longer,  and  when  it  is  withdrawn  it  may  be  replaced  by  a  second,  and 
that  by  a  third,  and  so  on.  Simpson  regularly  em- 
ployed this  means  of  dilatation.  Bennet^  prefers 
bougies  of  wax  or  gutta  percha  to  metallic  sounds. 
He  says  that,  when  used  cautiously,  good  results 
can  be  obtained  without  suffering,  and  in  cases  of 
slight  constriction  no  further  treatment  is  required. 
Wax  bougies  may  be  used  every  second  day  till  the 
canal  is  sufficiently  dilated ;  each  bougie  should  be 
kept  in  place  for  some  hours.  When  using  Simpson's 
metallic  sounds  Bennet  gives  them  a  slight  curve, 
with  the  concavity  on  the  anterior  surface,  that  they 
may  be  better  adapted  to  the  form  of  the  cervico- 
uterine  canal.  Sims  has  wisely  substituted  the  use 
of  aluminum  for  other  metals  in  the  manufacture  of 
these  dilators.  Aluminum  is  light,  not  easily  de- 
composed, and  more  readily  borne  than  any  other 
metal.  Nevertheless,  instead  of  making  use  of 
bougies  or  catheters  it  is  better  to  have  recourse  to 
dilating  bodies,  and  to  the  most  inoffensive  of  all, 
viz.  prepared  sponge. 

The  naturally  dilating  bodies  are  especially  useful  when  we  cannot 
at  once  succeed  in  passing  the  internal  orifice,  either  on  account  of  its 
excessive  narrowness,  or  on  account  of  deviation,  inflexion  or  torsion 
of  the  cervico-uterine  canal.  If  they  do  not  effect  the  complete  dila- 
tation of  this  canal  including  the  internal  orifice,  they  at  least  prepare 
the  way  for  the  penetration  of  instruments  through  this  orifice.  The 
treatment  may  be  completed  afterwards  by  incision  or  by  the  introduc- 
tion of  bougies  or  metallic  stems  into  the  cavity  of  the  womb.  The 
dilating  body  most  commonly  employed  is  prepared  sponge,  which 
should  be  applied  according  to  the  rules  previously  laid  down  (p.  149). 
Each  sponge-tent  should  penetrate  a  little  further  than  the  preceding 
one,  and  as  this  application  should  be  discontinued  during  menstrua- 
tion, one  or  two  months  are  often  required  to  produce  complete  dila- 
tation. Laminaria  may  be  substituted  for  sponge-tents  in  dilating  the 
external  orifice,  but  it  should  never  be  used  for  the  os  internum,  the 
swelling  of  the  laminaria  above  the  constriction  rendering  extraction  of 
the  stem  impossible  without  lacerations,  which  may  endanger  the  life 
of  the  patient.  Prepared  sponge  alone  ought  to  be  employed  in 
dilating  the  cervico-uterine  orifice,  and  as  I  do  not  see  any  advantage 
that  laminaria  has  over  sponge,  I  use  the  latter  exclusively  for 
the  dilatation  of  the  vaginal  orifice,  as  well  as  for  the  os  internum. 
Unfortunately  dilatation  is  often  insufficient,  especially  for  the  os 
externum. 

II.  Incision. — When  dilatation  appears  insufficient,  incision  of  the 
cervix  should  be  resorted  to.     This  little  operation,  to  which  the 
imposing  name  of  uterotomy  or  hysterotomy  has  been  given,  is  not  un- 
accompanied by  accidents  when  performed  inopportunely  or  too  deeply. 
1  Op.  cit.,  p.  338. 


DYSMENORRHCEA  311 

The  incision  may  be  single  or  multiple,  superficial  or  deep ;  it  may  be 
limited  to  one,  or  extended  to  both  orifices  of  the  cervix.  Some 
gynecologists  proscribe  division  of  the  os  internum  in  all  circumstances.^ 
As  for  myself,  I  have  often  remarked  that  obstruction  of  the  internal 
orifice  is  caused  by  a  curve  or  flexion  of  the  uterus,  a  tumour  on  a  level 
with  the  orifice,  or  simple  hypertrophy  of  the  upper  part  of  the  anterior 
cervical  wall ;  but  some  constrictions  are  produced  by  congenital  mal- 
formation, others  by  retraction  of  the  circular  or  oblique  fibres  of  this 
orifice,  and  others  again  by  true  contraction  of  the  sort  of  sphincter 
which  surrounds  this  orifice,  the  existence  of  which  seems  to  me  as 
clearly  proved  by  my  anatomical  investigations  as  by  the  physiological 
phenomena  I  have  observed.  I  acknowledge  that  incision  of  this  orifice 
is  much  more  dangerous  than  that  of  the  external  one ;  fortunately 
it  is  less  frequently  necessary.  Nevertheless  I  think  that  dilatation  by 
sponge-tents,  and  even  by  superficial  incision,  may  be  performed 
without  danger,  provided  that  suitable  precautions  be  taken  to  arrest 
haemorrhage  if  it  threaten  to  be  serious,  and  especially  by  avoiding 
operation  at  the  menstrual  period. 

It  is  only  accidentally  and  quite  exceptionally  that  division  of  the 
external  orifice  can  lead  to  any  accidents.  It  is  so  often  indicated 
that  we  must  give  up  all  hope  of  curing  a  large  number  of  uterine 
maladies  caused  by  a  narrow  vaginal  orifice  if  its  enlargement  is  to  be 
proscribed. 

Different  metJiods  of  incision. — The  utility  of  hysterotomy  being 
admitted,  all  that  remains  is  to  procure  the  best  instruments  and  dis- 
cover the  best  way  of  performing  the  operation.  I  began  by  using 
the  simplest  instruments  :  a  pair  of  long-handled  scissors ;  a  director 
with  a  long  stem  fitted  on  to  a  handle ;  a  bistoury  with  a  short  blade 
like  that  of  a  tenotome,  pointed  or  probe-pointed  according  to  cir- 
cumstances, with  a  long  stem  mounted  on  a  handle  which  could  be 
introduced  into  the  uterus  along  the  groove  of  the  director. 

I  will  describe  the  way  in  which  I  now  perform  the  operation  with 
the  same  instruments,  with  the  addition  of  a  pair  of  diverging  tena- 
culum hook  forceps ;  before  doing  so,  however,  I  shall  mention  the 
instruments  invented  for  the  same  purpose  by  other  gynecologists,  and 
which  in  some  cases  may  be  preferable  by  simplifying  the  operation 
and  rendering  it  more  rapid.  The  first  of  these  instruments,  Simp- 
son's^ hysterotome  (Fig.  208,  p.  227),  is  a  kind  of  concealed  bistoury, 
resembling  in  its  mechanism  the  lithotome  of  Friar  Come,  and  which 
requires  no  description.  Simpson,  after  incision,  always  applied  the 
tincture  of  perchloride  of  iron  or  the  glycerole  of  it  to  the  cervix  by 
means  of  a  brush,  and  he  plugged  if  necessary.  The  second,  the 
double  hysterotome,  several  varieties  of  which  have  been  invented  in 
France  and  England  (Fig.  209,  p.  227),  allows  of  the  incision  of  both 
sides  of  the  cervix  simultaneously.  If  Greenhalgh's  instrument  were 
less  complicated  and  less  costly  there  is  no  doubt  it  would  be  prefer- 

^  Discussion  at  the  Obstetrical  Society  of  London,  June  7,  ISGo.     Lancet, 
July  15th,  1865,  and  Obstetrical  Transactions,  1866. 
^  Op.  cit.,  p.  254. 


312  UTEEINE    DISEASES   IN    DETAIL 

able  to  others^  for  by  an  ingenious  contrivance  the  blades,  in  springing 
out,  cut  the  tissues  of  the  cervix  from  within  outwards  to  an  extent 
which  increases  in  proportion  as  they  advance  from  the  cervico-uterine 
orifice  to  the  utero-vaginal  one ;  besides,  the  divergence  of  the  two 
blunt  blades,  on  a  level  with  the  vaginal  orifice,  separates  the  walls  of 
the  vagina  from  the  sharp  blades,  and  stretches  the  tissue  of  the  cervix 
so  as  to  facilitate  incision.  The  analogous  but  simpler  instrument 
made  by  Mathieu^  although  far  from  presenting  the  regularity  and 
perfection  of  Greenhalgh^s,  is  often  useful.  Many  operators  prefer 
scissors  of  various  kinds  to  these  concealed  bistouries.  Kiichen- 
meister  has  invented  a  pair  of  scissors,  the  external  blade  of  which  is 
armed  with  a  point  which  penetrates  the  tissue  of  the  cervix  and  fixes 
the  instrument  at  the  desired  height.  Others  have  used  scissors 
with  toothed  blades,  to  make  the  section  a  kind  of  tearing,  so  as  to 
prevent  hsemorrhage. 

I  have  abandoned  scissors  as  well  as  simple  and  double  metrotomes, 
and  have  adopted  a  method  by  which  the  extent  of  the  incision  can  be 
better  controlled.  Incision  in  some  cases,  however,  being  insufficient, 
recourse  must  be  had  to  autoplasty.  I  shall,  therefore,  before  de- 
scribing these  operations  (incision  and  autoplasty)  explain  in  which 
cases  the  one  operation  ought  to  be  preferred  to  the  other. 

Indications  for  incision  and  autoplasty  afforded  hy  the  condition  of 
the  vaginal  orifice. — In  cases  of  congenital  narrowness  there  is  gene- 
rally a  want  of  depth  in  the  contraction  of  the  os  externum  (Pig.  233). 
This  may  depend  on  two  causes:  —  1.  On  the  contraction  of  the 
sphincter  (the  mucous  membrane  is  puckered,  as  is  often  the  case 
with  the  orifice  of  the  prepuce).  This  contraction  will  certainly 
yield  to  slow  dilatation  by  sponge  tents  or  to  rapid  dilatation  with 
simple  forceps,  the  blades  being  quickly  opened  after  their  intro- 
duction. 2.  On  the  scantiness  of  the  mucous  membrane  itself  (in 
these  cases  it  is  not  puckered) .  Slow  dilatation  may  be  tried ;  but 
incision  is  generally  necessary  ;  it  succeeds  because  the  two  folds  of 
mucous  membrane  (the  vaginal  and  cervical)  are  close  together  and 
easily  adhere  to  one  another  (this  may  be  aided  by  the  application  of 
fine  sutures).  Lastly,  the  widening  of  the  opening  caused  by  the  two 
lateral  incisions  persists  almost  completely,  because  the  tissue  of  the 
uterine  wall  is  thin  and  the  cervical  cavity  which  it  limits  is  very  large 
(Pig.  223). 

In  cases  of  accidental  constriction,  and  in  some  even  of  congenital 
narrowness,  the  constriction  is  of  some  depth.  In  place  of  an 
orifice  (o)  there  is  a  real  canal  (o  %')  (Fig.  234),  varying  in  length  and 
breadth.  If  the  external  mucous  membrane  of  the  vaginal  portion  of 
the  cervix  is  sufficiently  extensive,  the  same  cannot  be  said  of  the 
limited  internal  mucous  membrane,  separated  from  the  other  by  a  more 
or  less  considerable  thickness  of  tissue  proper,  and  unable  to  come 
into  contact  with  it,  both  on  account  of  its  insufficiency  (there  is  want 
of  material)  and  in  consequence  of  the  interposition  of  a  foreign  tissue 
in  the  regular  conformation  of  the  uterine  orifice.  If  this  canal  be 
divided  by  a  simple  incision  we  enter  an  insignificantly  small  cervical 


DYSMENOERHCEA 


313 


cavity.     The  internal  mucous  membrane  can  never  be  brought  into 
contact,  and  still  less  made  to  adhere  to  the  external  one,  and  the 


Fig.  233. — Congenital  pin-point  os  ex- 
ternum. The  orifice  o  has  no  depth. 
The  uteiine  cavities  which  are  behind 
are  dilated  by  the  accumulation  of 
retained  blood. 


Fig.  234. — Congenital  pin-point  os, 
having  the  depth  of  a  true 
canal  o  i  ;  the  fibro-muscular  tis- 
sue of  the  uteiTis  helps  to  make 
the  orifice.  The  uterine  cavities 
are  also  greatly  dilated. 


divided  tissues  will  unite  again,  either  directly  by  immediate  reunion, 
or  by  cicatrisation  and  the  gradual  retraction  of  each  commissure,  from 
the  angles  of  the  bilateral  incision  to  the  primitive  orifice.  In  such  a 
case  we  must  ensure  the  persistence  of  the  commissures  by  an  auto- 
plastic operation. 

1.  Division  of  the  orifice  by  bilateral  incisio?i. — The  method  I  have 
adopted  for  a  number  of  years  is  the  following:— In  order  to  fix  the 
uterus  and  at  the  same  time  to  give  to  the  tissues  the  tension 
requisite  for  clean  and  exact  incisions,  I  introduce  into  the  orifice 
my  long  diverging  tenaculum  hook  forceps  (see  Fig.  235),  one  hook  of 
which  penetrates  into  the  centre  of  the  anterior  lip,  the  other  into  the 
posterior.  By  opening  them  as  wide  as  possible  1  fix  the  cervix  and 
draw  it  a  little  towards  the  vulva  whilst  stretching  each  side  right  and 
left,  so  as  to  be  able  to  perform  the  section  slowly,  regularly,  and  to 
the  extent  which  seems  to  me  necessary .^  Two  fine  stitches  may  be 
applied  afterwards,  or  a  metaUic  suture  to  each  side.  As  a  rule  this 
is  not  necessary.  If  I  think  congestion  of  the  organ  renders  a  little 
bleeding  advisable  I  let  a  sufficient  quantity  of  blood  flow  after  the 

'  Olshausen  {Sammhuuj  Klinlscher  Vortraege  von  Volhnann,  No.  (j7,^  Leip- 
zig, 1874)  has  often  recourse  to  what  he  calls  bleeding  dilatation  ;  but  in  per- 
forming it,  like  me,  he  prefers  using  a  simple  probc-iwinted  bistoury. 


314 


UTERINE    DISEASES    IN    DETAIL 


Fig.  235. — Division  of  the  os 
externwm  by  bilateral  inci- 
sion. 


Fig.  236. — Instniment  for 
perforating  the  cervix  and 
passing  a  vegetable  or 
metallic  thread  through 
it ;  this  is  often  indispen- 
sable on  account  of  the 
resistance  and  hardness 
of  the  uterine  tissue  :  s, 
sound  penetrating  into  the 
cervix ;  a,  needle  pushed 
by  a  piston,  v,  through 
one  side  of  the  cervix  and 
retained  by  the  double 
hook  e. 


operation  and  then  plug  to  prevent  hsemorrhage.  The  patient  removes 
the  plugging  by  degrees,  beginning  the  second  or  third  day,  taking 
baths  or  at  least  injections,  which  greatly  facilitates  the  extraction  of 


DYSMENORRHCEA 


315 


the  cotton  wool.  Great  patience  and  care  are  required  to  prevent  the 
occurrence  of  haemorrhage  or  inflammation.  Rest  in  bed  should  be 
enjoined  for  a  few  days,  and  sometimes  the  additional  precautions  of 
cataplasms,  laxatives,  enemata  of  laudanum,  emollient  vaginal  injec- 
tions, &c.,  should  be  resorted  to.  If  necessary,  the  enlargement  of  the 
orifice  may  be  completed  by  the  application  of  sponge  tents,  but  not 
before  the  following  month. 

2.  Bilateral  division  by  means  of  elastic  ligatiire. — In  order  to 
ensure  the  permanence  of  this  dilatation  I  have  tried  to  perforate  each 
side  of  the  vaginal  portion  of  the  cervix  at  a  certain  distance  from  the 
orifice  by  means  of  a  special  instrument  (Fig.  236)  made  for  passing 
iron  or  silver  wire,  which  I  draw  tightly  after  the  following  monthly 
period,  tightening  it  gradually  till  the  tissue  has  been  completely 
divided.     Latterly   I   have   substituted   elastic  ligature   for   metallic 


Fig.  237. — Cervix,  through  which  an  elastic  ligature  has  heen  passed  right  and 
left  from  the  natural  to  the  artificial  orifice. 

wire,  performing  in  fact  an  operation  similar  to  that  for  anal  fistula. 
Making  on  both  sides  of  the  natural  orifice,  at  a  distance  df  1  or  2 
centimetres,  a  new  orifice,  I  pass  through  this  opening  an  elastic 
thread,  which  comes  out  at  the  os.  I  stretch  it  tightly,  and  after 
having  tied  it  firmly  with  a  wax  thread  leave  it.  The  bilateral  section 
is  effected  slowly,  and  I  have  often  the  satisfaction  of  seeing  the  large 
opening  that  has  been  made  remain  permanent. 


Fig.  238. — Autoplasty  by  the  formation  of  ai-tificial  commissures.  Dissection 
of  two  lateral  pieces  of  triangular  mucous  membrane  cc'  o',  hh'  o"  ;  circu- 
lar orifice  o. 


316 


UTERINE    DISEASES    IN    DETAIL 


HI.  Aiitoplasty} — lu  cases  where  tissue  is  wanting,  an  artificial 
uterine  orifice  must  be  made. 


Fig.  239. — Id.,  deep  lateral  incision  extending  from  the  narrow  circular  orifice 
0  to  the  centre  of  the  base  of  the  triangular  flaps  c(^  o',  bV  o". 

1.  Autoplastj/  hij  the  formation  of  artificial  commissures. — If  the 
orifice  is  narrow  but  the  cervix  not  conical,  I  dissect  lateral  triangular 
or   quadrangular  flaps;  when  these   are  turned   back   (Pig.  238)  I 


r^ 


Fig.  24:0.— Id. 


0'  0 

Fig.  241.— Id. 


stretch  the  orifice  well  with  my  diverging  tenaculum  hook  forceps, 
and  divide  it  right  and  left  (Fig.  239),  and  between  these  two  lips 
which  are  held  apart,~I  insinuate  into  each  bleeding  commissure  thus 
made  the  bleeding  surface  of  each  lateral  flap,  keeping  it  in  position 
by  means  of  one  or  two  simple  or  button  sutures  on  each  side  (Figs. 
240,  241).  The  threads  are  removed  sooner  or  later  as  in  vesico- 
vaginal fistulaj. 

The  results  of  these  autoplastics  are  most  interesting  (Pig.  242).  I 
have  seen  some  several  years  after  operation  in  which  the  enlargement 
of  the  orifice  with  solid  commissures  had  remained  intact.  In  the 
patients  who  had  undergone  this  operation  dysmenorrhoea  was  cured, 
and  in  several  pregnancy  had  occurred. 

2.  Autoplasty  by  excision  of  vjeiJge- shaped  pieces  of  fibrous  tissue 
and  turning  dozvn  the  fiaps  of  vaginal  or  external  vmcovs  viembrane  on 

^  Societede  chirurgie,  1872. — Montpellier  mediccd,  t.  xxx,  pp.  515,  522,  an. 
1873. 


DYSMENORRHCEA 


317 


to  the  cervical  or  internal  mucous  membrane. — When  the  cervix  is 
conical,  and  when,  consequently,  there  is  an  excess  of  fibrous  tissue  as 


Fig.  242. — JcZ.,  appearance  of  the  orifice  and  its  comniis.sures  after  the  removal 
of  the  sutures.  Later  on,  the  points  of  the  dissected  pieces  are  drawn  into 
the  commissures  by  the  retraction  of  the  cicatrix,  and  the  oi'ifice  becomes 
more  regular  (figure  drawn  from  nature). 

well  as  an  alteration  in  the  shape  of  the  organ,  autoplasty  is  facilitated 
by  the  excision  of  two  prismatic  portions  of  this  tissue  before  and 
behind,  and  by  the  suture  to  the  cervical  mucous  membrane  of  quad- 
rangular flaps  of  the  vaginal  mucous  membrane,  both  before  and  behind. 
(See  Pigs.  243 — 246,  and  their  explanations.) 


Fig.  21i. 


Fig.  243. — Quadrangular  flaps  of  external  mucous  membrane  of  the  cervix, 
meant  to  be  turned  down  towards  the  internal  mucous  membrane  after 
excision  of  a  prismatic  portion  of  the  tissue  proper. 

Fig.  244. — Plan  of  operation  :  v  v,  vagina  ;  m  to,  quadrangular  vaginal  flaps, 
designated  by  the  same  letters  as  in  Fig.  243  ;  c,  cervical  cavity  ;  a  a, 
dotted  lines  showing  the  limits  of  the  excision  of  a  prismatic  portion  of 
the  tissue  proper  ;  m'  in',  points  of  the  cervical  mucous  membrane  which 
are  to  be  united  to  points  mm  of  the  vaginal  mucous  membrane. 

3.  Autoplasty  hy  excision  of  conical  pieces  of  the  vaginal  portion  of 
the  cervix. — The  method  by   dissecting  quadrangular  flaps  which  I 


318 


UTERINE    DISEASES    IN    DETAIL 


have  just  described  has  been  imitated  by  Simon,  of  Heidelberg,  and 
described  bj  Max  Marckwald^  under  the  new  name  of  autoplasty  by 


Fig.  245. — Four  metallic  sutures  ap-  Fig.  246. — Plan  of  the  result  of  the 

plied  so  as  to   keep  the   anterior  operation :  v  v,  vagina ;  c,  cervical 

and   posterior  dissected   pieces  of  cavity  ;    mira,  points  of   union  of 

external  mucous  membrane  in  con-  the   dissected   pieces   of     external 

tact  with  the  lining  cervical  mem-  membrane  with  the  internal, 
brane. 

conical  flaps.  The  former  has  performed  it  sixteen  times,  the  latter 
four.  This  method  of  autoplasty  is  especially  suitable  to  hyper- 
trophied  elongation  of  the  cervix;  the  operation  fulfils  the  double 


Fig.  247. — Max  Marckwald's  method  Fig.  248. — Id.,  juxtaposition  of  the 

of  autoplasty  by  excision  of  conical  mucous  membranes.     The  sutures 

pieces.     Dissection  of   the  mucous  drawn  together, 
membrane.     Excision  of  the  pieces. 
Insertion  of  the  sutures. 

indication  of  diminishing  the  volume  of  the  cervix  and  making  as  large 
an  orifice  as  possible,  there  being  no  fear  of  subsequent  contraction, 
such  as  occurs  after  simple  division  of  the  cervix  or  after  excision  of 
the  whole  thickness  of  the  cervix  including  the  mucous  membranes. 
This  last  method,  however,  being  much  more  complicated  than  mine, 

'  Archivfilr  Gynaecologie,  Bd.  viii,  S.  48,  Berlin,  1875. 


DYSMENOEEHa]A  319 

ought  to  be  reserved  for  cases  in  which  it  is  indispensable  to  excise  a 
large  portion  of  the  cervix. 

3.    'Memhranous  BysmenorrTio&a. 

One  of  the  most  curious  maladies,  and  somewhat  similar  to  con- 
gestive djsmenorrhoea,  is  that  described  by  Oldham  in  1  846  under  the 
name  qI pseudo-membranous  dysmenorrliKa,  which  Simpson  studied  at 
the  same  time  under  that  of  pathological  exfoliation  of  the  uterine 
mucous  memhrane,  and  which  would  be  more  correctly  designated 
membranous  dysmenorrhma?-  Although  this  disease  is  far  from 
common,  the  singularity  of  this  sort  of  mould  of  the  uterine  mucous 
membrane  and  its  connection  with  the  decidua  have  attracted  the  atten- 
tion of  many  writers.  Besides  being  one  of  the  most  interesting 
forms  of  dysmenorrhoea,  it  is  one  of  which  the  very  existence  has  been 
the  subject  of  lively  debate.  Whilst  some,  with  Bernutz/  considered 
its  existence  as  established  beyond  question,  Robin^  and  others*  denied 
it,  founding  their  arguments  on  the  similarity  of  its  morbid  products 
with  those  expelled  a  month  or  six  weeks  after  conception.  This  can- 
not be  gainsaid;  I  mjself  have  often  recognised  products  of  abortion 
in  them. 

The  arguments  in  favour  of  membranous  dysmenorrhoea  are  drawn 
on  the  one  hand  from  the  fact  that  the  phenomenon  may  be  repeated 
regularly  every  month  till  cure  takes  place,  notwithstanding  the  dis- 
continuance of  marital  intercourse,  and  on  the  other,  that  it  has  been 
observed  in  virgins. 

I.  Many  cases  have  been  published  of  persistent  membranous  dys- 
menorrhoea in  married  women,  about  which  there  can  be  no  doubt. 
The  first  case  of  this  kind  which  is  carefully  recorded  is  Morgagni's.^ 
It  is  a  case  of  membranous  dysmenorrhoea  in  a  multipara  which  gradually 
disappeared  at  the  approach  of  the  menopause.  The  entire  eocfoUated 
mucous  membrane  was  expelled  in  the  form  of  a  bag. 

The  hollow  polypiform  tumour  due  to  dysmenorrhoea,  described  by 

'  Oldham,  London  Med.  Gazette,  1846,  vol.  ii,  p.  970. — Simpson,  Monthly 
Journal  of  Med.  Science,  Sept.,  1846,  p.  161. 

^  Bernutz,  op.  cit.,  p.  128. 

'  Gazette  medicale  de  Paris,  1857,  p.  761. 

■*  Raciborsl<i,  quoted  by  Aran,  p.  308.  Since  then,  however,  Eaeiborski  has 
admitted  the  fact  of  the  pathological  exfoliation  of  the  uterine  mucous  mem- 
brane (See  Traite  de  la  menstruation,  p.  559.     Paris,  1868). 

'"  Morgagni,  De  sedibus  et  causis  niorboruvi.  Letter  xlviii.  "  Of  false 
pregnancy,  abortion,  and  unhappy  delivery,"  §  12.  In  1814,  Moreaii  also,  in  his 
inaugural  thesis,  describes  the  existence  of  this  disease.  He  says,  "Evrat  has 
frequently  observed  that  sterile  women,  some  days  after  intercourse,  passed 
portions  of  membrane  analogous  to  the  decidua,  but  the  expulsion  of  these 
membranous  fragments  did  not  generally  take  place  till  the  monthly  period, 
and  was  invariably  accompanied  by  tension,  weight,  and  sometimes  by  dull 
hypogastric  pain  ;  may  we  not  reasonably  infer,"  he  adds,  "  that  the  excitement 
produced  by  coitus  is  sometimes  sufficient  to  determine  the  formation  of  the 
decidx;a  without  fecundation  having  taken  place."  Althoiigb  our  ideas  on  the 
nature  of  the  decidua  are  quite  different  from  those  of  Moreavi,  it  is  not  the 
less  true  that  these  exfoliated  and  expelled  mucous  membranes  are,  after  all,  a 
species  of  decidua. 


320  UTEETNE    DISEASES   IX    DETAIL 

Boivin  and  Dnges/  may  be  connected  with  this  same  disease,  as  also 
the  exfoliated  products  recognised  as  belonging  to  the  uterine  mucous 
membrane  by  Coste,  Lebert,  Eollin,  Dutard  and  Laboulbene,  whose 
■works  have  been  judiciously  revised  by  Semelaigne.^  One  of  the  cases 
published  by  Tyler  Smith/  another  published  by  Hegar,*  a  third  ob- 
served by  Tilt/5  ^^^  others  to  which  I  shall  afterwards  refer  are  examples 
which  seem  indisputable.  Troque,^  who  has  recently  published  an  in- 
teresting monograph  on  membranous  dysmenorrhoea,  relates  thirteen 
doubtful  and  fourteen  authentic  cases,  without  counting  those  of 
Lehnert  and  Eggel  which  I  shall  presently  quote,  that  of  BourgareP 
and  those  which  have  come  under  my  own  observation  during  the  last 
few  years.  There  is  no  doubt  that  the  product  expelled  at  every  men- 
struation was  not  always  examined  with  all  the  detail  of  which  a  micro- 
scopic examination  admits ;  the  monthly  repetition  of  the  phenomenon, 
however,  was  established,  and  the  existence  of  membranous  dysmenor- 
rhoea  cannot  be  doubted  when  patients  observe  the  most  absolute 
abstinence  from  sexual  intercourse  as  mine  have  done.^  In  this  way 
I  have  lately  observed  two  new  cases  of  undoubted  monthly  uterine 
exfoliation.  The  first  relates  to  a  patient  who  began  to  menstruate 
regularly  and  abundantly  at  sixteen  ;  at  twenty-one  she  had  a  natural 
labour  followed  by  chronic  metritis  cured  in  a  few  months,  at  least  to 
all  appearance  ;  at  thirty  tardy  and  insufficient  menses,  with  phenomena' 
of  abortion.  Since  then  membranous  dysmenorrhoea,  and  the  same 
whether  sexual  intercourse  was  discontinued  or  not.  The  expulsion 
became  more  painful  after  four  years.  Cauterisation  of  the  uterine 
cavity  with  nitrate  of  silver ;  result  almost  nil. 

The  other  case  is  that  of  a  young  woman  presenting  traces  of  rachitis 
and  some  scrofulous  symptoms;  married  for  two  years;  nullipara. 
Membranous  dysmenorrhcea  occurring  at  every  menstruation  and 
several  times  taken  for  abortion.  Leeches  applied  to  the  vaginal 
portion  of  the  cervix,  division  of  the  os.  Eetro-uterine  inflammation, 
probably  diathetic  ;  formation  and  spontaneous  opening  of  an  abscess. 
Death  from  consumption. 

1  have  noticed  that  a  large  proportion  of  the  patients  affected  with 
membranous  dysmenorrhoea  have,  like  the  above  named,  a  bad  con- 
stitution, are  weak,  lymphatic,  scrofulous,  or  disposed  to  tubercle. 
The  malady,  although  local,  seems  to  depend  upon  a  general  condition 
which  makes  the  probability  of  cure  very  uncertain.  On  the  other 
hand,  we  sometimes   find  a  tendency  to  the  same  disease  in  several 

^  Maladies  de  I'uterus,  t.  ii,  p.  419. 

2  De  la  Dijsmenorrliee  onembraneuse  et  de  la  mevihrane  dysmenorrheale. 
These  de  Paris,  Xo.  232,  annee  1851. 

3  The  Lancet,  18  June,  1855,  p.  608. 

4  Monatsschrift  filr  Geburtsh,  1863,  Bd.  xxii,  S.  176. 

^  Arch,  of  Med.,  1861,  yoI.  iii,  p.  96. — On  iiterine  and  ovarian  inflamma- 
tion (exfoliative  internal  metritis),  p.  267.     London,  1862. 

®  Ktvde  critique  sur  la  dysmenorrhee  mcmhraneuse.     Paris,  1869. 

"  Union  viedicale  de  la  Provence,  1864. 

®  Couriy,  Nouvelles  observations  de  dysmenorrliee  membraneuse,  in  Mont- 
pellier  medical,  t.  sxiii,  p.  215,  1869. 


DYSMENOEEHCEA  321 

women  of  the  same  family,  a  fact  to  be  taken  into  account  with  regard 
to  etiology.  Brouardel  has  communicated  to  Siredey  (Nouv.  diet,  de 
med.  et  de  chirurgie  pratiques,  art.  "  Dysmenorrhee"j  Duplan's  case  of 
a  girl  who  had  five  sisters,  all  of  whom  suffered  from  membranous 
dysmenorrhcea  ever  since  their  first  menstruation.  One  of  Siredey^s 
patients  has  a  sister  who,  like  herself,  has  suffered  from  membranous 
dysmenorrhcea. 

II.  The  montlily  exfoliation  of  the  mucous  membrane  has  not  been 
observed  as  frequently  in  virgins  as  in  married  women,  for  the  simple 
reason  that  membranous  dysmenorrhcea,  like  all  other  uterine  diseases, 
is  rarer  in  the  former  than  in  the  latter,  and  that  the  physician  is  taken 
less  into  the  confidence  of  the  former  with  regard  to  what  occurs  in 
the  course  of  a  menstrual  malady,  were  it  for  no  other  reason  than  the 
ignorance  and  want  of  observation  of  the  patient.  No  one,  however, 
engaged  in  scientific  research,  or  who  makes  minute  inquiries  into 
all  doubtful  cases  of  menstrual  disorders  occurring  in  a  large  gynae- 
cological practice_,  can  fail. to  meet  with  authentic  cases  of  the  malady 
in  question  in  virgins,  and  consequently  to  acquire  a  new  scientific 
proof  of  its  existence  independently  of  conception  and  abortion.  In 
this  way  I  have  collected  four  cases  of  membranous  dysmenorrhcea  in 
virgins,  which  are  not  without  interest.  The  first  was  observed  by 
Dubois  of  Neufchatel,^  and  is  a  case  of  expulsion  of  membrane  from 
the  uterus  at  the  monthly  period  in  a  girl  of  eighteen.  The  second 
case  is  that  of  a  girl  of  sixteen  expelHng  dysmenorrhoeic  membrane.^ 
The  third  case  is  one  of  membranous  dysmenorrhcea  existing  throughout 
the  virginity  of  the  patient  as  well  as  after  marriage.  The  case  is 
related  by  Eggel,-^  who  read  it  before  the  Gynaecological  Society  of 
Berlin,  when  several  members  admitted  the  existence  of  this  disease  in 
virgins.  Lastly,  I  have  myself  seen  a  case  of  membranous  dysmenor- 
rhcea in  a  virgin,  the  cause  of  which  was  obscure,  and  which  was  only 
ameliorated  by  partial  treatment. 

The  latter  series  of  cases  proves  that  the  exfoliation  of  the  uterine 
mucous  membrane  may  take  place  independently  of  any  abortion. 
The  membrane  which  is  expelled  periodically  presents,  it  will  be  seen, 
the  special  characters  of  the  uterine  mucous  membrane.  It  often  has 
the  triangular  form  of  the  cavity  of  the  body  of  the  uterus  (Fig.  249). 
Sometimes  it  is  divided  into  two  triangular  portions  ;  sometimes  it  is 
expelled  in  small  fragments  (Fig.  250).     When  it  is  passed  entire  it 

'  Dubois  of  Neufcliatel,  Gazette  med.  de  Paris,  1847,  p.  729  and  909. 

^  Monatsschrift  fur  GeburtsJcunde,  1868,  Bd.  xxxi,  S.  5. 

'  Eggel,  Monatsschrift  filr  GeburtsJcunde,  1869,  lid.  xxxiii,  S.  11.— Solowief 
A\ex2indre {Decidua menstrualis,  Archiv.  filr  Gynaekolocfie,  13d.  ii,  S.  66.  Berlin, 
1S71)  describes  the  case  of  a  girl  of  twenty-one  wbose  hymen  was  intact  and 
who  had  frequently  passed  fragments  of  exfoliated  mucous  membrane  after 
dysmenorrhcea.  Einkel  relates  another  case  of  expulsion  of  tlie  uterine 
mucous  membrane  in  a  virgin  in  whom  the  hymen  was  intact,  and  two  others 
in  women  who  had  abstained  from  sexual  intercourse  for  two  or  three  months 
{Archiv  filr  pathol.Anat.und  Physiol., Bd.  Ixiii,  1875).  Beigel  admits  also  tliat 
it  is  not  rare  to  meet  with  it  in  virgins  (Archiv  fiir  Gynaekologie,  Band  ix;, 
Heft  1). 

21 


322 


UTERINE    DISEASES    IN    DETAIL 


generally  presents  several  orifices ;  the  lower  one,  irregular,  with  the 
border  more  or  less  torn,  corresponds  with  the  os  internum ;  the  two 


Fig.  249. — Uterine  mucous 
membrane  expelled  en- 
tire, opened,  sho'n'ing  the 
smooth  internal  cavity 
perforated  with  glandular 
orifices,  and  the  external 
surface  covered  with  vil- 
losities,  the  extremities 
of  blind  tubular  glands. 
Preparation  in  St. 
Thomas's  Museum,  na- 
tural size  (after  Barnes). 


Fig.  250. — Portion  of  the  uterine  mucous 
membrane  expelled  in  dysmenon-hoea 
(after  Oldham).  It  is  the  first  figure 
ever  given  of  the  exfoliated  mucous 
membrane.  There  are  two  others  in 
Tilt's  work  {On  Uterine  and  Ovarian 
Inflammation,  p.  266  etseq.  London, 
1862),  and  another  in  Henning's 
Memoiv{MonatsscJiriftfurGeburts'k., 
1864).  The  monthly  expulsion  of 
the  mucous  membrane  generally 
takes  place  in  this  way,  in  fragments. 


others,  which  are  very  small  and  situated  at  the  two  upper  angles  of 
the  expelled  product,  correspond  with  the  ostia  uterina.  The  colour 
is  usually  deep  red ;  the  external  surface  is  villous,  sometimes  infil- 
trated with  small  clots  of  blood,  whilst  the  internal  surface  is  perforated 
with  holes  corresponding  with  the  glandular  orifices,  and  is  smooth  to 
the  touch.  Vannoni  has  observed  that  when  the  sac  is  inverted 
during  its  expulsion  from  the  uterus  the  villous  surface  may  be  found 
within. 

As  a  rule  the  external  surface  is  very  slightly  villous  ;  the  villosities 
may,  however,  acquire  a  considerable  size,  as  Henning,  of  Leipsig,  has 
seen.^  In  this  case,  described  under  the  name  of  villous  dysmenor- 
rJicea,  it  is  difficult  to  admit  that  the  villosities  belong  to  a  chorion, 
and  that  the  expelled  membrane  is  a  product  of  abortion,  as  the  phe- 
nomenon was  repeated  six  times,  and  each  time  at  an  interval  of  exactly 
a  month.  Although  this  case  is  very  different  from  the  preceding  ones, 
it  seems  to  be  an  additional  example  of  exfoliative  dysmenorrhcea. 
Examined  by  the  microscope,  the  product  presented  the  structure  of 
the  uterine  mucous  membrane,  only  differing  from  the  decidua  by  the 
slighter  development  of  its  capillary  vessels,  by  the  small  amount  of 

1  Monatsschriftfiir  GeburtsTc.,  1864,  Bd.  xxiv,  S.  130. 


DYSMENOEEHCEA  323 

its  special  cells  and  of  its  epithelium,  which  is  of  the  prismatic  instead  of 
the  pavement  variety,  like  that  of  the  decidua  at  the  second  month.  This 
product  contained  a  great  quantity  of  debris  of  utricular  or  blind  glands. 
The  causes  of  this  pathological  exfoliation  are  very  obscure.  Oldham 
explains  nothing  in  attributing  it  to  ovarian  influence  ;  this  influence 
has  neither  been  proved  nor  defined.  Tilt/  in  a  communication  to  the 
London  Medical  Society,  connects  it  with  an  inflammatory  condition  ; 
in  a  later  pubhcation,  however,  he  justly  remarks  that  the  latter  is  not 
only  the  cause  but  the  consequence  of  the  passage  of  the  sac  or  of  this 
kind  of  delivery  which  occurs  monthly.  Scanzoni  says  he  has  only  seen 
one  case  in  which  there  was  not  an  appreciable  alteration  of  the  womb  ; 
in  all  others,  the  uterine  walls  were  the  seat  of  a  chronic  engorgement, 
or  there  were  flexions,  fibroids  or  polypi.  As  for  myself,  I  do  not  know 
of  a  single  case  in  which  the  disease  was  not  preceded  by  more  or  less 
disturbance  of  the  economy  or  of  the  uterus,  shown  by  painful  and 
irregular  menstruation.  It  seems  to  me  to  be  the  result  of  a  san- 
guineous congestion,  a  kind  of  apoplexy  of  the  mucous  membrane  -^  in 
support  of  this  opinion  we  may  refer  to  the  small  clots  found  infiltrated 
in  the  expelled  product,  adding  that,  like  apoplexy,  it  may  be  produced 

'  The  Lancet,  1853. — Several  authors,  commencing  with  Andral  {Anat. 
pathol.,  t,  ii,  p.  681.  Paris,  1829),  and  including  Huchardand  Labadie-Lagrave, 
attribute  the  exfoliation  of  the  uterine  mucous  membrane  to  inflammation  or 
irritation.  They  call  it  menstrual  metritis  (Archiv.  gen.  de  med.,  1870)  ; 
Kaschewai'owa  {ZJeher  die  Endometritis  decidualis  chronica,  mMonatssch.filr 
Geburtsk.,  Bd.  xxxii,  Heft  5).  In  some  cases  the  inflammatory  nature  of  the 
disease  cannot  be  denied,  as  in  Labadie-Lagrave 's  cases  {vaginitis,  endometritis, 
membranous  dijsinenorrhoza  for  nineteen  years,  antiphlogistic  treatment  and 
cure)  and  in  Huchard's  (membranous  dysmenorrhcea  connected  with  tnenstrual 
metritis  for  thirty -tioo  years,  contrast  between  the  amelioration  of  the  sym- 
ftoms  in  the  intercalary  period  and  their  aggravation  at  each  monthly  period, 
improvement  from  the  use  of  emollients.  Huchard  and  Labadie-Lagrave, 
Contributions  a  I'etude  de  la  dysmenorrhee  membraneuse  {Arch.  gen.  de  med. 
de  Paris,  1870-72).  We  do  not,  however,  consider  that  this  form  of  dys- 
menorrhoea  is  necessarily  the  consequence  of  inflammation,  nor  that  it  should 
be  designated  exfoliative  endometritis  as  Beigel  suggests  {Arch.filr  GynaeJcol., 
Bd.  ix,  Heft  1.  Berlin,  1876).  Gaillard  Thomas  is  also  of  our  opinion  (op.  cit., 
p.  595). — Besides,  we  know  that  membranes  analogous  to  those  referred  to  are 
found  in  the  uterus  at  other  times  than  the  monthly  period,  and  there  is  no 
reason  why  inflammation  should  have  more  share  in  the  formation  of  the  one 
than  of  the  oihev  {Chronit  Slawjansky,  Endometritis  decidualis  hemorrhagica 
hei  Cholerahranhen,  in  Archiv  fur  Gynaecol. ,Bd.  iv,  S.  285.  Berlin,  1872). — 
Other  authors,  e.  g.  Mandl  {Zur  Pathologic  und  Therapie  der  Dysmencn-rhcea 
membranacea,  Wiener  medical  Presse,  1869,  No.  1  to  16.  Monatssch.  filr 
Geburtsk.,  Bd.  xxxiv,  Heft  5.  Berlin,  1869),  regard  it  as  special  {morbus  sui 
generis),  whilst  following  Robin  and  Haussmann  some  consider  it  early  abortion 
(avortement  ovulaire)  ;  but  if  so,  it  should  be  possible  to  recognise  it  by  its 
form,  structure,  &c. 

-  For  which  reason  Hegar  and  Eigenbrodt  have  given  it  the  name  of  apo- 
plectic dysmenorrhcea.  Besides,  the  thrombic  accumulations,  the  real  sub- 
mucous apoplectic  centres  prove  the  existence  of  sanguineous  efEusions,  which 
associated  with  uterine  contractions  would  be  the  chief  secondary  causes  of  the 
exfoliation  of  the  uterine  mucous  membrane.  The  membrane  is  separated 
from  the  subjacent  surface  by  a  fibrinous  layer  containing  free  round  cells 
(Beigel)  or  by  real  apoplectic  centres,  the  results  of  sub-epithelial  or  sub- 
mucous sanguineous  extravasations  (Huchard  and  Labadie-Lagrave). 


324  UTEEINE   DISEASES    TN   DETAIL 

in  the  absence  of  any  organic  alteration  of  the  womb ;  the  mucous 
membrane  must  also  have  a  special  tendency  to  exfoliation.  As  to 
dysmenorrhcea,  strictly  so  called,  although  it  usually  accompanies  ex- 
foliation, it  may  be  wanting  without  the  malady  losing  its  distinctive 
character,  which  is  the  expulsion  of  the  mucous  membrane.  Exfolia- 
tion and  expulsion  of  the  mucous  membrane  are  the  anatomo-patho- 
logical  elements  of  the  disease  in  question.  Mayer,^  of  Berlin,  relates 
the  case  of  a  married  lady,  twenty-seven  years  of  age,  who  was  sterile, 
and  who  suffered  from  the  monthly  exfoliation  of  a  thick  and  consistent 
membrane  without  dysmenorrhoea.  The  dysmenorrhoeic  pain  depends 
solely  on  the  relation  between  the  size  of  the  expelled  membrane  and 
the  orifice  through  which  it  has  to  pass. 

A  little  reflection  on  the  special  nature  of  uterine  diseases  will  con- 
vince us  that  there  is  nothing  so  very  extraordinary  in  membranous 
dysmenorrhcea.    The  same  properties  characterise  the  organs  and  tissues 
in  the  evolution  of  their  pathological  processes  as  in  the  accomplish- 
ment of  their  physiological  processes.     Many  pathological  phenomena 
are  only  an  impairment  or  an  exaggeration  of  physiological  ones.   With 
various  degrees  of  reaction  to  pathogenic  causes,  the  tissues  respond 
to  the  action  of  these  causes  in  the  same  way  that  they  respond  to  the 
causes  which  normally  elicit  the  display  of  their  activity.     Now  the 
uterine  mucous  membrane  becomes  hypertrophied  and  is  exfoliated  by 
the  physiological  act  of  parturition,  and  by  the  pathological  act  of 
abortion   (intermediate    between    the  exfoliation   of   parturition   and 
that  of  dysmenorrhoea).     Is  it  surprising   that,  under  the  influence 
of    a    uterine    disease    which    places     the    tissues    in    a    condition 
analogous  to  that  of  the  beginning  of  pregnancy  and  abortion,  this 
mucous  membrane  should  be  exfoliated  in  the  same  way,  although  it 
does  not  contain  any  product  of  conception  ?    In  this  case  an  abnormal 
process  takes  place  analogous  to  what  occurs  normally  under  the  in- 
fluence of  conception.     This  process   commences  at  the  ripening  of 
every  ovum  in  the  ovary,  at  the  dehiscence  of  every  Graafian  vesicle,  at 
every  menstrual  period.    The  mucous  membrane  swells  and  commences 
to  hypertrophy,  as  if  in  preparation  for  a  possible  conception.     It  is 
this  periodical  hypertrophy  of  the  mucous  membrane  which  has  been 
described  by  Aveling  under  the  name  of  nidation,  and  in  place  of  hyper- 
trophy Aveling,2  WilliamSjS  and  others  admit  a  monthly  development, 
a  new  formation  after  every  menstruation.     This  new  uterine  mucous 
membrane  formed  during  each  intercalary  period,  is  supposed  to  be 
entirely  detached  and  expelled  every  month,  owing  to  fatty  degeneration 
and  disintegration  with  subjacent  haemorrhage,  and  to  disappear  with 
the  menstrual  discharge  in  fragments  which  escape  observation.  There- 
fore Avehng  calls  it  the  nidal  decidua  to  distinguish  it  from  the  decidua 
of  gestation.    Membranous  dysmenorrhoea  is,  according  to  this  theory, 
only  an  exaggeration  of  this  phenomenon. 

1  Beitrdge  zur  Geburtskwnd.  und  GynaeJcol.,  Bd.  iv,  Heft  1,  S.  33.  Berlin, 
1875. 

^  London  Obstetrical  Journal,  July,  1874. 
3  Id.,  Februaiy  and  March,  1875. 


DYSMENORRHGEA  325 

The  formation  of  a  new  mucous  membrane  every  month  is  not  proved, 
and  I  think  the  exfoliation  of  this  membrane  is  only  an  exceptional  fact. 
The  only  thing  really  proved  is  the  enormous  hypertrophy  of  the  uterine 
mucous  membrane  at  every  menstrual  period.  An  excess  of  this  hyper- 
trophy is  sufiicient  to  constitute  an  obstacle  to  the  discharge  of  the 
menstrual  blood  and  a  local  cause  of  the  detachment  of  the  mucous 
membrane  by  subjacent  sanguineous  effusion.  It  is  not  even  necessary 
to  suggest  this  hypothesis.  In  fact  when  fecundation  does  not  take 
place,  the  uterine  mucous  membrane  resumes  its  normal  condition,  and  all 
congestion  and  erection  ceases  in  the  utero-ovarian  system.  If, 
however,  this  regressive  atrophy  (the  analogue  in  miniature  of  the 
retrograde  evolution  following  delivery)  is  absent  owing  to  a  local 
malady  or  a  general  condition  reacting  on  the  uterus,  there  will  be  a 
great  risk  of  exfoliation  of  the  mucous  membrane  taking  place. 
Now,  I  have  observed  that  the  majority  of  women  affected  with 
membranous  dysmenorrhoea  are  thin,  delicate,  chlorotic,  rachitic  or 
scrofulous. 

All  writers  have  made  the  same  remark ;  and  some  physicians 
consider  this  malady  merely  as  the  localisation  of  a  variable  diathetic 
affection,  the  nature  of  which  is  not  yet  clear,  but  the  existence  of 
which  is  probable,  since  it  is  sometimes  seen  in  several  women  of  the 
same  family  (p.  321).  If  some  refuse  to  see  in  membranous  dys- 
menorrhoea the  localisation  of  a  general  affection,  they  cannot  deny 
that  the  reaction  of  the  disease  is  sometimes  propagated  to  more  or 
less  distant  organs  ;  for  instance,  a  propagation  of  this  kind  may 
produce  real  exfoliative  enteritis;^  it  is  perhaps  a  propagation  of  the 
same  kind  which  causes  buccal  ichthyosis,  and  which  has  led  Gautier, 
of  Geneva,^  to  suppose  that  the  disease  in  question  is  only  uterine 
ichthyosis,  detached  in  patches.  To  sum  up,  there  is  a  connection 
between  membranous  dysmenorrhoea  and  morbid  conditions  of 
other  organs  till  now  imperfectly  determined,  but  which  deserves 
attention. 

Diagnosis. — The  symptoms  of  this  affection  are  those  of  congestive 
dysraenorrho3a,  frequently  aggravated  by  complications.  When  un- 
complicated, the  disorders  only  exist  at  the  monthly  period. 
Scaiizoni^  observed  in  one  of  his  patients  an  acute  pain  in  the  renal 
and  umbilical  regions,  occurring  eight  or  even  fifteen  days  before  the 
menses  appeared  ;  this,  however,  is  exceptional,  usually  pain  appears 
only  the  evening  before  menstruation.  It  seems  to  cease  all  at 
once  with  the  appearance  of  the  discharge,  but  recommences  shortly 
afterwards  with  renewed  intensity.  It  is  at  first  congestive  or  in- 
flammatory, with  a  feeling  of  fulness  in  the  pelvis,  heat,  tension  at  the 
hypogastrium,  in  the  loins,  and  in  all  the  pelvic  cavity.  It  afterwards 
becomes  expulsive  and  intermittent,  assuming  the  character  of  labour 
pains,  of  real  uterine  contractions  which   may   be  transformed  into 

'  Huchard  and  Labadie-Lagrave  {Archiv.  gen.  de  medecine,  1870). 
*  Congrhs  international  des  sciences  medicales,  5*  session,  p.  4G0.  Geneva, 
1878. 

^  Op.  cit.,  p.  335. 


326  UTEEINE    DISEASES   IN  DETAIL 

cramp,  which  requires  to  be  calmed  in  order  to  regulate  contraction 
and  facilitate  the  expulsion  of  the  caducous  membrane.  At  last,  after 
repeated  alternations  of  exacerbation  and  comparative  relief,  lasting 
from  four  to  six  hours,  a  more  or  less  extensive  membrane  is  expelled 
either  at  once  or  at  different  times  in  fragments,  and  from  this 
moment  there  is  a  diminution  of  the  violence  of  the  pains.  After 
expulsion  there  is  a  pale  red  discharge  soon  replaced  by  one  altogether 
mucous  in  character.  At  the  next  monthly  period  the  same  scene  may 
be  repeated  with  more  or  less  violence  ;  only  the  membrane  may  be  less 
extensive,  and  may  no  longer  represent  the  mould  of  the  uterine 
cavity  exactly.  This  indicates  an  improvement  which  may  either 
be  due  to  treatment  or  to  natural  causes,  giving  us  reason  to  hope 
that  cure  is  not  far  off. 

It  is  not  uncommon  for  exfoliation  and  expulsion  of  the  uterine 
mucous  membrane  to  coincide  with  other  serious  pathological  states. 
These  concomitant  phenomena  are :  general  deterioration  of  health, 
ansemia,  chlorosis,  scrofula,  tuberculosis,  leucorrhoea,  chronic  endo- 
metritis, repeated  formation  of  false  membranes,  of  coagulation  of 
mucus,  of  epithelial  desquamation  of  other  organs,  such  as  the  tubuli 
uriniferi  in  catarrhal  nephritis,  the  trunks  of  the  bronchi  and  the 
trachea,  the  larynx,  the  pharynx  as  the  seat  of  pultaceous  angina,  &c. 
Glairy  enteritis  (not  including  dysentery,  diphtheria  and  thrush)  and 
exfoliative  enteritis  (Heyfelder,  Siredey,  Huchard,  &c.)  have  been 
observed  simultaneously  with  exfoliative  metritis,  as  have  also  analogous 
alterations  of  the  mucous  membrane  of  the  bladder  (Luschka,  Vir- 
chow's  Archiv  ;  Deneffe,  Bulletin  de  la  Soc.  anat.  de  Paris,  1 862 ; 
Spencer  Wells,  Obstetric.  Transact,  vol.  iv)  and  of  the  vaginal  mucous 
membrane  (Tyler  Smith,  Farre,  Vannoni,  Tilt,  Delore). 

Differential  diagnosis. — Membranous  dysmenorrhoea  must  be  dis- 
tinguished from  abortion.  There  are  differences,  as  Raciborski^  says, 
which  enable  us  to  distinguish  them ;  the  dysmenorrhoeic  expulsive 
pains  precede  the  monthly  hsemorrhage,  whilst  heemorrhage  precedes 
the  pains  of  abortion ;  in  the  former  the  cervix  is  closed,  in  the 
latter  it  is  open ;  the  dysmenorrhoeic  membrane  is  generally  in  frag- 
ments, that  of  abortion  more  or  less  entire;  if  entire,  the  former  is 
rather  triangular  (moulded  on  the  uterine  cavity),  the  latter  ovoid  ;2 
the  former  is  often  an  incomplete  decidua,  in  which  a  great  number 
of  elements,  glandular  and  vascular  especially,  are  wanting,  the 
latter,  like  every  gravid  decidua,  is  thicker,  richer  in  vascular 
arborisations,  and  even  showing  a  trace  of  the  spot  where  the  ovum^ 
w^as  lodged;  the  former  is  only  expelled  at  the  menstrual  period  which 
is  not  delayed,^  the  latter  at  other  times,  independently  of  menstru- 

^  Traite  de  la  menstruation,  p.  559.  Paris,  1868, 

*  See  the  form  of  this  decidua  of  aboi-tion,  compared  with  that  of  the  dys- 
menorrhoeic membrane  (fig.  249)  in  a  drawing  added  to  my  paj^er  entitled, 
Mecanisme  habituel  de  I'avortement  dans  les  premiers  mois  de  la  grossesse, 
&c.,  Montpellier  medical,  t.  v,  pp.  215,  428,  &c.,  1860. 

^  Gillet  de  Grandmont,  De  la  muqueuse  iiterine  et  de  son  evolution  pendant 
la  menstruation  et  la  grossesse.  Inaugural  thesis.    Paris,  1864. 

^  This  expulsion  occuriing  always  at  the  menstrual  period  may  be  repeated 


DYSMENOREHIEA  327 

ation,  usually  after  some  delay^  that  is  to  say,  its  expulsion  is  pre- 
ceded by  a  gestatory  amenorrhcea  (however  short)  ;  the  former  has  a 
cylindrical,  the  latter  a  pavement  epithelium  ;  the  former  is  often 
accompanied  by  symptoms  of  metritis  and  inflammatory  exudations,  the 
latter  by  neither.  It  is  important  to  notice  these  diff'erences  in 
forming  a  prognosis  and  to  confirm  them  by  enjoining  strict  discon- 
tinuance of  marital  intercourse ;  for  if  it  is  a  question  of  mem- 
branous dysmenorrhcea  an  unfavorable  prognosis  as  to  a  future  preg- 
nancy will  be  given ;  if  it  is  a  question  of  abortion  the  prognosis 
will  be  relatively  favorable  to  another  pregnancy,  at  least  propor- 
tionately to  the  gravity  of  the  causes  which  have  produced  the 
abortion. 

The  expulsion  of  the  exfoliated  mucous  membrane  has  often  been 
confounded  with  that  of  other  products  of  the  womb.  Apart  from 
clots  of  blood,  we  know  that  a  certain  number  of  products,  appa- 
rently membranous,  may  come  from  the  uterus.  But  an  attentive, 
minute  histological  examination,  aided  by  the  microscope,  will  not 
fail  to  detect  profound  differences  under  apparent  analogies.  The 
apparently  similar  membranous  products  which  may  be  expelled 
from  the  uterus  may  be  classed  under  three  heads  :  1,  coagulations  of 
mucus  presenting  the  characters  of  inflammatory  exudations,  moulded 
on  the  uterine  cavity,  and  preserving  sufiicient  consistency  to  be 
expelled  under  the  form  of  entire  pseudo- membranes,  being  sometimes 
formed  of  several  homogeneous  layers  or  plastic  concretions  which 
increase  their  thickness  and  tenacity,  and  may  give  rise  to  an  exudative 
djjsmenorrlicea ;^  the  desquamation  there  efl'ected  is  sometimes  only 
the  first  stage  of  the  malady  followed  by  exfohation  which  will  take 
place  later  on;  'i,,  false  memhranes  strictly  so-called,  analogous  to  those 
M'hich  are  formed  on  other  mucous  membranes  from  slight  epidermic 
exfoliations  lined  with  coagulations  of  mucus,  analogous  to  those  of 
thrush  and  to  more  serious  exfoliations  lined  with  fibrinous  products, 
separating  from  the  dermis  of  the  mucous  membrane  only  by  ulceration 
or  laceration,  which  are  of  the  same  nature  as  croupous  membranes  and 
equally  serious,  hence  the  name  of  diphtheritic  metritis.  We  may  there- 
fore give  the  name  oi pseudo-membranous  or  diphtheritic  dysmenorrhea^ 
to  this  disease  ;  3,  lastly,  the  uteririe  mucous  membrane  itseU ,  which  is 
separated  from  the  underlying  tissue  as  at  delivery  or  at  miscarriage 
or  at  a  simple  abortion,  and  which  is  expelled  sometimes  entire  in  the 
form   of  a  sac,  with  external  or  internal  villosities  according  as  it 

consecutively  for  eight  years  (Case  of  Veit,  Christot),  ten  years  (Hucliard), 
fifteen  years  (Mandl),  in  fact  indefinitely. 

'  No  one  doubts  the  reality  and  nature  of  these  exudations  and  of  these 
coagulations  of  mucus. 

^  This  name  has  been  adopted  by  Huchard  and  Labadie-Lagrave  {Contribu- 
tion a  I'etude  de  la  dysmenorrhee  memhraneuse,  Paris,  1873,  and  Arch,  de 
med.,  loc.  cit.).  Boggs  (Notes  et  reflexions  chirurgicales  sur  les  phlegmasies  de 
la  matrice.  Theses  de  Paris,  18(36)  ;  Hervieux  (Traite  clinique  et  pratique  des 
maladies  puerperales,  t.  i,  p.  240.  Paris,  1870)  ;  Krieger  {Die  menstruation^ 
eine  gynaehologisclie  Studie,  S.  196.  Berlin,  1869)  ;  Scanzoni  (op.  cit.,  p.  335)  ; 
Churchill  (op.  cit.,  p.  218). 


328 


UTERINE    DISEASES    IN    DETAIL 


passes  directly  or  inverted^  sometimes  in  more  or  less  considerable 
fragments,  sometimes  in  small  shreds,  but  always  with  its  characteristic 
elements,  its  glands,  epithelium,  &c.  It  is  for  the  disease  characterised 
by  the  exfoliation  and  expulsion  of  the  uterine  mucous  membrane 
itself  that  we  must  reserve  the  name  of  membranous  or  exfoliative 
dysmenorrhcea} 

Lastly,  besides  products  of  the  womb,  there  are  also  membranous 
debris  from  the  vagina  (epithelial  vaginitis  of  Tyler  Smith  and  Tarre, 
Archives  of  Med.  1856-59,  vol.  i,  p.  71),  sometimes  even  real 
moulds  of  the  vagina,  expelled  by  patients,  as  described  by  A.  Parre 
[Beale's  Archives)  and  Barnes  (op.  cit.,  p.  217),  which  must  not  be 
confounded  with  membranes  produced  by  dysraenorrhceic  uterine 
exfoliation,  and  which  differ  in  every  respect.  Besides  the  difference 
in  the  macroscopic  and  microscopic  characters  of  the  expelled  pro- 


FiG.  251. — Exfoliated  vaginal  mucous    membrane,  forming  a  mould  of    the 
vagina,  in  St.  Thomas's  Museum  (Barnes). 

ducts,  it  is  sufficient   to   add,  to  complete  the  diagnosis,  that  the 
vaginal  products  are  always  expelled  without  dysmenorrJmic  pains. 

Treatment. — Although  this  disease  does  not  involve  risk  of  life,  it 
is  serious,  not  only  because  of  the  monthly  suffering,  but  also  on 
account  of  the  reproductive  functions.  It  is  all  the  more  important  to 
treat  it,  as  Beigel  justly  remarks,  because  it  is  a  cause  of  sterility  and 
abortion.      I   have   collected   several   cases   in   which  abortion   was 

'  Savietti  {Contribution  a  l' etude  cle  la  caduque  menstrnelle.  Turin,  1869)  ; 
Bolowiei  {Deciduamenstrualis,  Archiv  f.  Gynaek.,  Bd.  ii,  S.  68,  1870) ;  Hegar 
and  Mayer  {Beitrdge  zur  Pathologie  des  Eies,  Virchow's  Archiv,  Bd.  ii,  S.  161 
1871). 


DTSMENORRHCEA  329 

undoubtedly  connected  with  this  morbid  state,  and  a  number  of 
others,  in  which  this  disease  was  so  evidently  a  cause  of  sterility  that 
in  several  conception  followed  the  cure  of  the  malady.  The  patient 
whose  history  is  related  by  Henning  is  a  striking  example  of  this  : 
after  having  expelled  these  membranous  products  six  times  during 
the  first  six  months  of  her  marriage,  she  was  cured  so  completely 
that  three  months  afterwards  she  became  pregnant  and  had  a  good 
delivery. 

I  may  here  quote  two  other  equally  authentic  cases  of  cure  of 
membranous  dysmenorrhoea.  I  could  mention  several  others,  but  do 
not  wish  to  put  before  the  reader  any  cases  as  to  which  there  could  be 
the  slightest  doubt. 

The  first  case  is  an  example  of  membranous  dysmenorrhoea  in  a 
virgin  with  aggravation  of  symptoms  after  marriage. — Sterility, — 
Amelioration. —  Widowhood,  cure, — Second  marriage. — Two  preg- 
nancies followed  by  delivery  at  term.  It  is  probable  that  the  con- 
solidation of  the  cure  by  widowhood  was  the  indirect  cause  of  the 
cessation  of  sterility  at  the  commencement  of  the  second  marriage. 

The  second  case  is  an  example  of  membranous  dysmenorrhcea  occur- 
ring after  marriage  and  an  abortion. — Slight  retroflexion,  leucorrhoea, 
menorrhagia. — Long  duration  of  the  disease. — Cure  after  a  long  con- 
tinued, general  treatment,  tonic  and  anti-diathetic,  and  slight  cauterisa- 
tions followed  by  tonic  apphcations  to  the  uterine  mucous  membrane. 
It  is  evident  that  in  these  two  cases  the  disease  was  of  an  inflammatory 
nature.  That  does  not  imply  that  an  analogous  treatment  would  not 
succeed  even  when  symptoms  of  metritis  were  less  accentuated.  We 
must,  however,  remember  that,  membranous  dysmenorrhoea  being 
frequently  connected  with  a  serious  disturbance  of  the  constitution,  we 
must  try  to  modify  the  constitution  by  general  treatment,  more  fre- 
quently tonic,  alterative  and  anti-diathetic  than  anti-phlogistic.  The 
local  treatment  is  less  difficult  to  institute. 

The  treatment  varies,  not  only  according  to  the  patients  and  their 
constitution,  but  also  according  to  the  stage  at  which  the  physician  is 
consulted  and  the  complications  which  may  co-exist.  Eeferring 
the  reader  for  these  latter  to  the  chapters  devoted  to  them.  I 
will  confine  myself  now  to  mentioning  what  should  be  done  in  the 
simplest  cases,  those  in  which  the  inflammatory  element  is  the  only 
complication  to  be  feared.  Whatever  the  case  may  be,  the  primary 
indication  at  the  time  of  suffering  is  to  alleviate  and  diminish  the 
pain;  preparations  of  opium  given  internally  should  be  associated 
with  belladonna  or  chloroform  liniments  applied  to  the  abdomen.  In 
the  intercalary  period,  however,  it  will  be  well  to  apply  some  leeches 
to  the  cervix  and  to  cauterise  the  uterine  cavity  with  nitrate  of  silver. 
Although  these  means  have  often  succeeded,  especially  in  the  hands 
of  Tilt,  they  have  also  failed ;  Scanzoni  has  cauterised  for  whole 
months  without  obtaining  the  slightest  alleviation.  These  failures 
chiefly  depend  on  the  nature  of  the  compHcations :  when  they  cannot 
be  combated  successfully  the  dysmenorrhoea  resists  all  therapeutic 
efforts. 


330  UTERINE  DISEASES  IN  DETAIL       , 

To  prevent  the  formation  of  membranes,  especiallj  in  exudative  or 
pseudo-membranous  and  even  in  diphtheritic  dysmenorrhcea,  we  may- 
resort  to  the  injection  of  a  saturated  solution  of  chlorate  of  potash  or 
to  crayons  of  chlorate  of  potash  introduced  every  two  days  into  the 
uterine  cavity  ;  they  are  sometimes  completely  dissolved,  at  other  times 
reduced  to  small  fragments  in  twelve  hours.  Injections  of  a  strongly- 
alkaline  solution  of  bicarbonate  of  soda  may  act  favorably  on  the 
mucous  membrane.  Solowief^  has  proposed  electricity  for  the  same 
purpose. 

When  the  dysmenorrhoeic  symptoms  seem  to  be  produced  by  want  of 
proportion  between  the  uterine  orifice  and  the  membrane  which  has 
to  be  expelled  we  may  follow  the  example  of  Tyler  Smith,^  who  relieved 
a  patient  by  introducing  a  metal  stem  into  the  cervix  in  order  to  dilate 
mechanically.  This  question  requires  more  investigation.  It  seems 
to  me,  that  in  the  majority  of  cases,  the  local  indications  are  limited  as 
follows  : — 1,  by  dilatation  or  incision  to  render  the  uterine  orifice  easy 
to  pass ;  sufficient  attention  is  not  paid  to  this  matter :  prepared 
sponge  is  in  such  cases  an  excellent  means  of  dilatation  and  of  render- 
ing the  tissues  supple ;  2,  to  modify  the  internal  surface  of  the  organ 
by  catheretics  or  slight  caustics,  such  as  fine  injections  of  saturated 
solution  of  chlorate  of  potash  (the  action  of  which  on  the  mucous 
membranes  is  so  efficacious),  or  of  nitrate  of  silver,  tannin,  perchloride 
of  iron,  iodine,  or  of  very  weak  solutions  of  arsenic  or  mercury,  or 
even  chloride  of  zinc  greatly  diluted.  It  is  only  by  modifying  the 
tissue  of  the  mucous  membrane  and  its  vitality  more  or  less  ener- 
getically that  we  can  hope  to  arrest  this  continued  tendency  to 
exfoliation. 

The  treatment  which  I  have  found  most  successful  consists  in 
dilating  the  cervix  with  sponge-tents,  the  dilating  and  resolvent  action 
of  which  is  assisted  by  the  use  of  belladonna  ointment,  the  application 
of  mercurial  ointment  to  the  hypogastrium,  by  small  rectal  injections 
of  iodide  of  potassium,  by  emollient  and  alkaline  baths,  and  by  a  tonic 
and  antiphlogistic  general  treatment,  in  which  hydropathy  should  not 
be  forgotten ;  the  surface  of  the  uterine  mucous  membrane  should  be 
modified  simultaneously  by  the  direct  application  of  chlorate  of  potas- 
sium, nitrate  of  silver,  tannin,  iodine,  perchloride  of  iron,  ointment  of 
red  precipitate  of  mercury,  &c.,  according  to  the  predominance  of  the 
local  indication.  During  the  whole  time  of  treatment  the  general 
health  should  be  particularly  attended  to,  tonics,  alteratives,  a  good 
regimen,  exercise,  hydropathy,  mineral  waters  being  prescribed  as  may 
be  specially  indicated;  in  this  way  we  must  try  favorably  to  modify 
the  constitution,  which  in  its  turn  will  exercise  a  beneficial  influence 
on  the  uterus. 

Uteeine  Neuralgia 

Uterine  neuralgia  or  hyderalgia  is  hke  the  neuralgia  of  all  other 
organs,  a  serious  disorder  of  sensibihty,  characterised  by  acute  pain, 

'  Archivf.  Gynaecolog.,  Bd.  viii,  S.  3.    Berlin,  1875. 
2  The  Lancet,  16  June,  1875. 


UTERINE    NEURALGIA  331 

independent  of  any  other  morbid  state  such  as  congestion,  inflamma- 
tion, &c.,  which,  however,  may  co-exist  with  it.  Whilst  believing 
that  neuralgia  is  usually  the  localisation  of  diathetic  affections,  such  as 
catarrh,  rheumatism,  arthritis,  gout,  herpetism,  &c.,  I  admit  that  it 
may  be  developed  temporarily  in  an  organ  as  a  simple  morbid  act, 
resulting  from  the  existence  of  a  local  or  general  pathological  condition. 
Hysteralgia  is  what  the  ancients  called  a  disease  without  matter,  a 
transition  point  between  simple  local  uterine  diseases  without  neoplasm, 
and  those  maladies  depending  on  a  general  affection,  characterised  by 
an  organic  alteration. 

J)ia(/7wsis.—l>i onaV-  distinguishes  primitive  hysteralgia,  occurring 
suddenly,  in  which  the  nervous  pain  commences  in  the  uterus  and  is 
propagated  into  various  regions  of  the  body,  from  secondare/  hys- 
teralgia manifested  subsequently  to  a  neuralgia  developed  on  some 
other  point  of  the  organism.  He  also  distinguishes  idiopathic  from 
symptomatic  hysteralgia.  The  latter,  which  may  depend  on  metritis, 
pen-uterine  phlegmon,  &c.,  does  not  seem  to  me  to  be  as  important  as 
the  former ;  for  it  is  accompanied  by  symptoms  foreign  to  the  neuralgia 
itself,  and  yields  to  the  treatment  of  the  dominating  malady.  As  for 
idiopathic  neuralgia,  although  it  is  a  disease  without  matter,  it  is  not 
only  nervous  and  essential,  but  also  diathetic  like  sciatica  and  all  other 
neuralgias. 

Uterine  neuralgia  usually  coexists  with  lumbo-abdominal,  lumbo- 
sacral or  intercostal  neuralgia.  Valleix  ^  considers  uterine  neuralgia 
as  nothing  more  than  the  mode  in  which  these  morbid  states  are 
manifested,  i.e.  as  a  lumbo-abdominal  neuralgia,  of  which  the  most 
painful  spot  is  situated  in  the  uterus.  The  majority  of  practitioners 
look  upon  uterine  neuralgia  as  primitive,  and  the  pain  produced  in  the 
various  nerves  of  the  lumbar  plexus  as  only  sympathetic  or  sympto- 
matic irradiations.  Struck  by  the  coincidence  of  uterine  neuralgia 
with  cervico-brachial,  facial,  supra-orbital  and  especially  with  inter- 
costal neuralgia,  Bassereau  ^  admits  that  the  painful  condition  of  the 
uterus  reacts  through  the  branches  of  the  great  sympathetic  on  the 
intercostal  nerves  determining  neuralgia.  There  may  assuredly  be 
irradiation,  or  reflex  action,  or  coexistence  of  two  neuralgias  under  the 
influence  of  a  common  morbid  affection. 

It  is  probably  this  malady  which  Gooch  "*  designated  by  the  name 
of  irritable  uterus.  Although  several  writers  have  attributed  his 
description  to  metritis  or  to  the  painful  contractions  which  any  kind 
of  disorder  may  excite  in  the  organ,  I  think  that  the  name  of  perma- 
nent dysmenorrhoea,  which  he  also  gave  it,  leaves  no  doubt  as  to  the 
nature  of  the  pain  and  its  continuity  during  the  intercalary  periods  as 

'  Op.  cit.,  p.  393. 

^  Traite  des  nevralgies  et  Bullet,  gen.  de  tlier.,  Jan.,  1847. — Guide  du  viede- 
cin  praticien,  t.  v,  p.  195.  Paris,  18G1. 

3  Essai  sur  la  n^vralgie  intercostale  consideree  comme  symptomatique  de 
quelques  affections  viscerales.   Tiieses  de  Paris,  1840. 

^  On  the  more  important  diseases  pecidiar  to  women,  p.  332.  London,  1831. 
— See  also  Genest,  Gazette  medicale,  1830,  pp.  323,  385  ;  St-ott,  Gazette  medic. 
1834,  p.  809 ;  Balling,  Neue  Zeit.f.  Geburtsk.,  Bd.  i,  S.  21,  2nd  case. 


332  UTERINE    DISEASES    IN  DETAIL 

well  as  during  menstruation.  It  is  this  character  of  spontaneous  and 
continued  pain,  hardly  interrupted  for  an  hour^  often  seated  in  the 
lower  part  of  the  uterus,  quite  different  from  uterine  colics  or  expul- 
sive pain,  sometimes  causing  intolerable  suffering  at  the  slightest 
movement  or  touch,  radiating  into  the  lumbar  plexus,  which  allows  of 
our  diagnosing  hysteralgia  and  distinguishing  it  from  other  painful 
states  of  the  womb.  This  is  all  the  more  striking,  as  usually  it  is 
only  the  isthmus  and  the  mucous  membrane  of  the  body  of  the  uterus 
that  are  sensitive.  The  sensibility  of  other  parts  is  very  dull ;  the 
cervix  apparently  having  none. 

The  pain  varies  in  nature  from  the  sensation  of  itching,  irritation, 
intolerable  heat  to  that  of  intense  shooting  pain  in  the  uterus  and  in 
the  course  of  the  nerves  just  referred  to.  It  is  often  confined  to  one 
side  of  the  pelvis.  It  may  be  aggravated  by  heat  as  well  as  by  move- 
ment. It  prevents  sleep  or  interrupts  it  suddenly  by  a  fit  of  pain. 
It  is  greatly  increased  by  the  cervix  being  touched,  and  I  have  seen  it 
accompanied  by  contraction  of  the  vulvo-vaginal  sphincter. 

It  is  generally  worse  a  few  days  before  the  menses,  without,  however, 
interfering  with  the  regularity  of  menstruation,  it  does  not  necessarily 
hinder  the  free  exit  of  blood,  and  consequently,  while  liable  to  be 
confounded  with  nervous  dysmenorrhoea  on  account  of  the  develop- 
ment of  pain  and  the  dysmenorrhoeic  symptoms  which  may  complicate 
it,  it  may  be  distinguished  by  the  freedom  with  which  the  catamenial 
discharge  takes  place,  and  by  the  absence  of  the  expulsive  "pains  cha- 
racteristic of  uterine  colic. 

The  differential  diagnosis  is  certainly  difficult  when  there  are  com- 
plications. Por  example,  nervous,  congestive  or  even  mechanical 
dysmenorrhoea,  congestion,  inflammation,  hypertrophy  of  the  uterus, 
peri-uterine  inflammations,  prolapse  of  the  uterus  and  vagina,  with  the 
very  painful  draggings  thereby  caused,  organic  lesions  such  as  cancer, 
hysteria  and  the  local  phenomena  accompanying  it,  are  all  morbid 
states  which  may  be  mistaken  for  neuralgia  owing  to  the  pain  which 
they  cause.  Therefore  great  care  should  be  taken  to  discover  if  any 
of  these  lesions  exist;  for  hysteralgia  is  so  rare  that,  however  violent 
and  persistent  the  pain  may  be,  we  should  always  presume  that  it  is 
symptomatic  of  some  one  of  these  morbid  states  rather  than  of  hyster- 
algia. Graily  Hewitt  regards  it  as  being  only  a  symptom  of  retro- 
flexion ;  in  a  supposed  case  of  uterine  neuralgia  related  by  Allison,^ 
the  autopsy  disclosed  a  serious  peri-uterine  inflammatory  lesion. 
Even  the  effects  of  uterine  neuralgia  help  to  conceal  its  true  nature  ; 
leucorrhoea  in  fact  may  accompany  it  as  a  symptom,  just  as  salivation 
and  tears  accompany  neuralgia  of  the  trifacial,  and  whilst  in  the 
majority  of  cases  we  are  liable  to  be  misled  in  attributing  to  a  sup- 
posed hysteralgia  the  pains  produced  by  another  disease,  so  on  the 
other  hand  we  may  overlook  hysteralgia  when  it  really  exists,  attribut- 
ing the  suffering  to  leucorrhoea  which  is  only  one  of  its  symptoms. 

^  Paiuful  affection  of  the  cervix,  excision,  cure ;  deatli  the  following  year. 
The  post-mortem  examination  showed  adhesions  uniting  the  uterus  to  the 
hladder  and  rectum  [Gazette  mkl.  de  Paris,  1843,,  p.  301). 


UTEEINE    NEURALGIA  333 

The  characteristics  of  neuralgia,  however,  are  sufficiently  well  marked 
by  the  pains  just  described  which  are  accompanied  by  great  sensibility 
of  the  neighbouring  tissues,  sharp  attacks  of  pain  with  slight  inter- 
mittence,  shooting  pains,  &c.  The  seat  of  hysteralgia  may  also 
require  to  be  diagnosed  ;  it  is  sometimes  in  the  body  but  more  fre- 
quently in  the  cervix,  according  to  Malgaigne  3^  it  may  even  be  con- 
fined to  the  right  or  left. 

Treatment. —  Hysteralgia,  although  not  a  fatal  illness,  is  very  serious, 
owing  to  its  duration  and  the  extreme  difficulty  of  curing  it.  Of  three 
patients  Scanzoni^  only  saw  one  cured,  and  even  this  cure  was  effected 
spontaneously  as  the  result  of  marriage,  the  disease  having  resisted  all 
treatment.  The  two  other  patients  were  treated  in  vain  by  several 
physicians.  We  must  therefore  attack  the  evil  early  and  by  general  and 
local  means  powerful  enough  to  give  some  hope  of  a  good  result.  The 
treatment  must  necessarily  vary  with  the  nature  of  the  neuralgia. 
Judging  from  my  own  practice^  I  think  half  of  all  the  cases  of 
neuralgia  are  connected  with  rheumatism  or  an  analogous  diathesis. 
Therefore  we  ought  to  prescribe  a  treatment  appropriate  to  this  malady, 
sulphur  or  alkaline  mineral  waters,  vapour  baths  and  hydropathy 
which  is  the  best  sedative  as  well  as  an  excellent  means  of  treating 
rheumatism  in  young  women.  In  addition,  we  must  prescribe  the 
general  or  local  treatment  suitable  for  the  special  nervous  form  charac- 
terising the  neuralgia,  which  is  neither  simple  pain  nor  spasm. 

The  most  efficient  internal  remedies  are  narcotics  and  antispasmodics, 
associated  with  tonics  and  even  with  iron  according  to  the  indication. 
Sulphate  of  quinine  with  digitalis  or  aconite  has  produced  very  good 
results  in  many  cases,  especially  when  the  neuralgia,  as  is  often  the 
case,  assumes  an  intermittent  or  periodic  type.  When  necessary,  the 
attacks  may  be  alleviated  by  inhalations  of  chloroform,  and  local 
sedatives  should  be  applied  to  the  hypogastrium,  uterus  and  rectum. 
The  transcurrent  cauterisation  recommended  by  Nonat  may  also  be 
tried  on  the  lower  part  of  the  abdomen,  or  better  still  hypodermic 
injections  of  morphia  may  be  given.  Suppositories  or  small  injec- 
tions containing  laudanum  or  belladonna  may  be  introduced  into  the 
rectum  till  narcotism  is  produced ;  or  vaginal  irrigations  may  be 
made  with  decoctions  of  hemlock,  poppy  heads,  or  belladonna  in  sitz- 
baths  of  the  same  composition.  Carbonic  acid  or  chloroform  spray 
may  be  applied  to  the  cervix.  Aran  advises  the  local  application  of 
ice,  or  better  still  of  laudanum.  Malgaigne  who,  with  the  majority  of 
Trench  writers,  thinks  hysteralgia  much  more  common  than  it  is, 
recommends  division  of  one  or  both  lips  of  the  cervix. 

The  best  of  all  local  applications  is  the  hypodermic  injection  of 
morjjhia  or  atropine.  It  has  been  suggested  that  these  injections 
should  be  made  into  the  uterine  tissue  itself,  but  the  latter  is  so 
vascular  that  it  bleeds  at  once  on  being  punctured,  and  so  the  injec- 
tion is  apt  to  be  lost ;  besides,  patients  atlected  with  uterine  neuralgia 

1  Sur  la  nevralgie  du  col  de  I'uterus,  &c.  Revue  medico-chirurgicale,  avril, 
1848. 

2  Scanzoni,  op.  cit.,  p.  339. 


334  UTEEINE   DISEASES    IN    DETAIL 

suffer  terribly  when  the  cervix  is  touched.  Therefore  it  is  better  to 
make  these  punctures  in  the  hypogastrium  at  some  painful  point  corre- 
sponding to  the  ramifications  of  the  lumbo-abdominal  branches.^  The 
puncture  is  made  into  a  fold  of  the  skin,  and  as  soon  as  the  injection 
is  made  the  finger  should  be  applied  to  the  skin  as  the  canula  is  with- 
drawn so  as  to  prevent  the  return  of  the  fluid ;  the  puncture  is  then 
covered  by  a  drop  of  collodion,  when  a  local  and  general  narcotism  is 
rapidly  obtained.  The  injection  should  be  repeated  sufficiently  often 
to  prevent  the  return  of  pain,  and  the  points  of  puncture  should  be 
varied  according  to  necessity. 

In  addition  to  these  injections  chloral  may  be  given  to  procure 
sleep,  and  bromide  of  potassium  for  the  hysterical  symptoms.  It  is 
very  seldom  that  these  three  principal  means,  aided  by  some  of  the 
accessory  measures  mentioned,  such  as  belladonna,  henbane,  supposito- 
ries, fomentations,  &c.,  do  not  temporarily  alleviate  the  sufi'ering,  whilst 
we  must  trust  to  mineral  waters,  alteratives,  specifics,  &c.,  for  attacking 
the  source  of  the  evil,  i.  e.  the  diathetic  affection  (rheumatism,  herpes, 
&c.)  which  is  generally  the  hidden  cause  of  uterine  neuralgia. 

I  have  obtained  such  satisfactory  results  from  these  means  that  I 
am  convinced  that,  when  associated  with  hydropathy,  they  constitute 
the  most  efficacious,  if  not  the  only  efficacious  treatment  of  hysteralgia. 


Uterine  Hemorrhage 

Uterine  hcemorrhage  may  occur  under  three  different  circumstances  : 
— I,  in  the  unimpregnated  uterus  ;  2,  during  pregnancy;^  3, 
after  delivery  or  abortion.  These  latter  forms  depend  generally  on 
special  causes  which  have  to  be  studied  in  connection  with  pregnancy 
and  delivery — that  is  to  say,  with  the  conditions  which  produce  them. 
I  shall,  therefore,  confine  myself  to  the  first  kind. 

Uterine  haemorrhage  occurring  in  the  unimpregnated  state  is  called 
menorrhagia  when  it  is  apparently  only  an  exaggeration  of  the  monthly 
period,  and  metrorrhagia  when  it  is  independent  of  the  menses.  It 
may  assume  various  forms :  the  quantity  of  blood  discharged  in  the 
same  time  may  be  greater  than  usual  (a  phenomenon  which  often 
depends  on  a  disorder  of  the  mucous  membrane) ;  or  the  periods  may 
last  longer,  the  result  being  the  same,  though  due  to  a  different  cause 
(generally  to  the  persistence  of  congestion);  or  they  may  recur  more 
frequently,  thus  giving  a  different  character  to  the  malady  (connecting 
it  with  more  frequent  ovulation).  Lastly,  there  may  be  an  intermenstrual 
discharge  of  blood  independent  of  menstruation,  and  constituting  a 
symptom  of  an  organic  disorder  or  morbid  state  similar  to  that  which 

^  De  l'effi,cacite  des  injections  narcotiques  sous-cutances  dans  le  traitement 
des  nevralgies.    Montpellier  medical,  Courty,  October  and  November,  1859. 

'  Coui'ty,  Memoire  sur  le  mecanisme  hahituel  de  Vavortement  dans  les  <pre- 
Tniers  mois  de  la  grossesse,  &c.,  Montpellier  medical,  1860.  Barnes,  Lectures 
on  Obstetrical  Operations,  2nd  edition.     London,  1871,  p.  387. 


UTEEINE    H^MOERHACxE  335 

obtains  in  other  organs  under  the  name  of  hsemorrhage,  and  which 
alone  therefore  has  a  right  to  the  name  of  metrorrhagia. 

Uterine  haemorrhage  is  also  an  important  symptom,  and  occurs  so 
frequently  that  it  deserves  the  serious  attention  of  the  physician.  It 
may  be  idiopathic  or  symptomatic. 

1.  The  possibility  of  idiopathic  metrorrhagia  has  been  wrongly  denied. 
It  is  not  uncommon  for  the  menses  to  be  occasionally  more  abundant 
than  usual  without  the  existence  of  any  abnormal  condition.  In  some 
women  they  may  be  less  abundant  one  month,  and  increased  in 
quantity  the  following  month ;  or  having  been  retarded  or  suppressed 
they  may  return  abundantly,  as  if  to  compensate  for  the  temporary 
suspension.  Frequent  cases  of  this  kind  occur  at  the  menopause. 
They  often  alternate  or  coincide  with  congestions  or  hseraorrhoids,  and 
like  these  may  disappear.  No  anatomical  alteration  is  to  be  seen  in 
the  uterus  beyond  a  temporary  distension  of  the  capillaries.  There  are 
some  cases  on  record  of  metrorrhagia  terminating  in  death  which 
could  not  be  explained  by  the  existence  of  any  lesion. 

Case  1. — West'  has  related  a  case  of  deatt  from  metrorrhagia  in  which  no 
other  lesion  could  be  found  than  a  small  clot  in  the  cavity  of  the  womb,  with- 
out any  alteration  in  the  mucous  membrane.  In  another  case  the  autopsy  is 
not  given. 

Case  2. — Obre'^  has  seen  the  same  occur  in  a  virgin  of  fourteen  years,  in 
whom  the  first  menstrual  discharge  could  not  be  arrested.  Everything  was 
normal  except  the  uterine  mucous  membrane,  which  was  softened  and  ecchy- 
mosed  and  detached  fi-om  the  muscular  layer  in  several  places. 

Case  3. — Whitehead-''  has  seen  a  similar  case;  only  here  menstruation  had 
been  regularly  established  for  four  years.  When  the  girl  was  seventeen  she  fell 
on  the  ice  in  the  street,  and  sustained  a  severe  shock.  Ten  days  after  the 
menses  appeared,  and  were  followed  by  profuse  haemorrhage,  which  lasted  five 
or  six  days,  from  the  effects  of  which  she  only  recovered  in  ten  or  twelve  days. 
The  catamenia  returned  the  following  month,  and  lasted  for  sixteen  days.  The 
next  menstrual  period  they  returned,  but  a  few  days  afterwards  they  were 
rejjlaced  by  a  metrorrhagia,  which  it  was  impossible  to  control,  and  which  ter- 
minated fatally  in  thirteen  days.  At  the  autopsy  no  organic  lesion  was 
discovered.  The  uterus  was  nuUiparous,  rather  larger  than  usual ;  its  walls, 
although  less  firm  than  usual,  were  of  normal  thickness.  It  contained  a  clot  of 
blood,  which  filled  the  cavity ;  the  appendages  were  normal. 

Menorrhagia  is  more  frequently  idiopathic  than  metrorrhagia :  e.  g. 
premature  and  tardy  menstruation,  uterine  epistaxis,  hsemorrhages  from 
excessive  ovarian  pain,  from  prolonged  uterine  erection,  from  inertia 
and  disturbance  of  vaso-motor  innervation. 

2.  Symptomatic  metrorrhagia  occurs  very  often,  more  so  than 
dysmenorrhcea  or  symptomatic  amenorrhoea.  It  happens  more  frequently 
in  the  intercalary  period  than  during  menstruation ;  it  often  continues 
almost  uninterruptedly  from  one  period  to  another  with  exacerbations 
corresponding  sometimes  with  the  menses,  sometimes  not. 

Metrorrhagia  may  be  symptomatic  of  local  diseases  or  of  general 
affections  not  localised  on  the  uterus.  Amongst  local  diseases  may  be 
reckoned  hemorrhagiparous   congestion,   defective   involution,   rarely 

'  West,  op.  cit.,  p.  65. 

^  British  Medical  Journal,  1857  ;  Gazette  mid.  de  Paris,  1856,  p.  596. 

'  London  Medical  Gazette,  1846  ;  Archives  de  medccine,  1846,  t.  xii,  p.  483. 


336  UTEEINE    DISEASES    IN    DETAIL    • 

metritis,  sometimes  softening  of  the  uterine  tissue  or  alterations  in  the 
mucous  membrane  (granulations,  fungosities,  exfoliations,  ulcerations),^ 
very  often  polypi,  hydatidiform  or  fleshy  moles,  fibroma,  cancer ;  less 
frequently  hematoceles,  peri-uterine  inflammation,  ovaritis,  organic 
lesions,  cystic  or  otherwise,  of  the  ovary,  especially  in  their  first  stages, 
deviations,  flexions,  &c.  As  for  ovarian  neuralgia,  the  influence  which 
it  is  said  to  have  in  producing  hsemorrhage  has  been  greatly  exagge- 
rated. Amongst  general  affections  we  may  mention :  the  acute  exan- 
themata, smallpox,  measles,  scarlatina,  typhoid  fever  (in  the  course  of 
which  uterine  epistaxis  may  occur),"  and  above  all  the  hgemorrhagic 
diathesis,^  the  influence  of  which  is  felt  upon  the  uterus  as  well  as  upon 
all  other  organs;  sometimes  plethora,  but  more  frequently  impoverish- 
ment of  blood  from  Bright's  disease/  chloro- anaemia,  scorbutus,  &c.  : 
lastly,  blood  stasis  in  the  system  of  the  vena  cava  inferior  from  incom- 
petence of  the  mitral  valve,  mitral  constriction,  hypertrophy  of  the 
heart,  development  of  abdominal  tumours  or  other  chronic  maladies. 
In  fact  it  is  much  more  common  than  idiopathic  hsemorrhage.  It  is 
characterised  by  frequent  recurrence  and  persistency. 

Diagnosis. — It  is  a  differential  diagnosis  that  is  required.  It  is  not 
difficult  to  assure  ourselves  that  the  blood  comes  from  the  uterine 
cavity,  but  it  is  not  so  easy  to  decide  whether  we  have  to  do  with 
monorrhagia  or  metrorrhagia;  whether  the  hsemorrhage  is  symptomatic 
or  idiopathic,  active  or  passive,  &c.  The  knowledge  of  the  causes  and 
analysis  of  the  symptoms  facilitate  this  diagnosis.  Amongst  the  pre- 
disposing causes  age  should  be  taken  into  consideration.  Middle  age 
is  the  period  when  haemorrhages,  like  all  other  uterine  diseases,  are 
most  common.  Metrorrhagia  is  also  very  common  at  the  menopause, 
constituting  one  of  its  most  remarkable  phenomena.  Brierre  de 
Boismont^  has  observed  fifty-seven  cases  out  of  141  women  arrived  at 
the  climacteric.  It  is  difficult  to  believe  that  metrorrhagia  can  be  idio- 
pathic after  the  menopause.  We  know  very  little  as  to  the  influence 
of  constitution,  temperament,  general  health,  &c.  The  influence  of 
hygienic  agents  seems  to  be  undoubted.  According  to  Saucerotte,^ 
women  who  inhabit  the  highest  points  of  the  Yosges  are  subject  to 
haemorrhages.  The  influence  of  hot  climates  or  change  of  chmate, 
and  the  abuse  of  hot  baths,  as  in  the  East,  is  certain.  What  are  we 
to  think  of  that  of  alcohol,  of  the  abuse  of  hot-water  bottles,  and  of  so 
many  other  real  or  imaginary  causes  to  which  great  importance  has 
been  attached  ? 

Probably  a  more  real  predisposing  cause  is  to  be  found  in  the 
structure  of   the  uterus  itself,  its  mucous   membrane,  its   muscular 

^  Occasionally  more  serious  alterations  produce  metrorrhagia  ;  e.g.  the  case 
related  by  Grailly  Hewitt  of  fatal  ha3morrhage  after  delivery,  diie  to  a  trau- 
matic aneurism  of  the  uterine  artery  {Obstet.  Transact.,  v.  ix,  p.  246.  London, 
1867). 

^  Upon  utei-ine  epistaxis,  so  called  by  Giibler.  V.  supra,  p.  410. 

■''  Gendrin,  Traite  de  med.  philos.,  t.  ii. 

"*  West,  op.  cit.,  p.  54. 

5  Op.  cif.,  p.  223. 

^  Melanges  de  chiriirgie,  p.  25. 


UTERINE    H^MOEEHAGE  337 

tissue,  its  vascular  system,  the  activity  of  its  circulation,  the  inertia  of 
its  muscular  tissue,  &c. 

Among  determining  causes  simple  physical  acts  (a  blow,  a  fall,  the 
application  of  leeches  to  the  cervix)  may  give  rise  to  metrorrhagia, 
which  may  assume  the  character  of  active  hsemorrhage  if  it  is  the  result 
of  the  violence  of  the  reaction  rather  than  of  the  traumatism  itself;  but 
sexual  excitement,  violence  of  menstrual  moliraen,  excessive  inter- 
course, especially  in  the  case  of  prostitutes,^  as  well  as  influences  of 
the  same  kind  on  neighbouring  organs,  e.  g.  repeated  drastic  pur- 
gatives, are  all  causes  which  rather  increase  the  activity  of  the  haemor- 
rhage than  originate  it.  Although  moral  impressions  more  frequently 
suspend  menstruation,  they  may  exceptionally  produce  an  excessive 
flow  of  the  menses,  or  even  metrorrhagia. 

The  symptoms  of  metrorrhagia  are  those  of  haemorrhages  in  general : 
progressive  debility,  pallor,  chilliness,  especially  of  the  extremities, 
small  pulse,  tingling  in  the  ears,  giddiness,  &c.  Those  of  essential 
or  idiopathic  metrorrhagia  are  variable.  Sometimes  the  discharge  of 
blood  and  even  uterine  fluxion  are  intermittent,  the  blood  flows  to 
the  uterus  in  jerks,  the  loss  seems  to  cease  or  at  least  diminish  in  con- 
siderable proportions,  but  it  soon  returns  with  violence ;  at  other 
times  the  discharge  of  blood  is  continuous,  without  pain  or  colics,  but 
with  increasing  loss  of  strength.  Sometimes  the  discharge  is  pure 
blood,  red  or  black,  but  liquid ;  at  other  times,  after  an  apparent  in- 
terruption or  after  the  excretion  of  a  certain  quantity  of  sanguinolent 
serum,  more  or  less  voluminous  clots  are  passed  accompanied  by  uterine 
colics  indicating  alternations  of  distension  and  contraction  of  the 
organ. 

Those  of  symptomatic  metrorrhagia  are  symptoms  peculiar  to  each 
of  the  morbid  states  of  which  the  haemorrhage  may  be  symptomatic. 
We  must  beware  of  confounding  metrorrhagia  or  menorrhagia  with 
the  consequences  of  an  abortion  at  the  commencement  of  a  pregnancy. 
Women  are  apt  to  mislead  the  physician  by  attributing  the  unforeseen 
and  abundant  recurrence  of  menstruation  to  a  delay  of  the  monthly 
period.  Generally  this  delay  is  due  to  pregnancy  and  the  recurrence 
is  an  abortion,  as  shown  by  the  nature  of  the  pains,  which  are  real 
uterine  colics,  and  by  the  expulsion  of  an  embryo,  a  villous  placenta, 
or  a  decidua,  on  which  a  circular  groove  may  be  seen,  indicating  the 
point  where  the  ovum  was  lodged.  The  likelihood  of  this  should 
always,  therefore,  be  present  to  our  mind,  and  a  careful  examination 
should  be  made.  Active  and  passive  haemorrhage  should  also  be  dis- 
tinguished ;  for  symptomatic  metrorrhagia  itself  may  be  either  active 
or  passive,  the  result  of  a  simple  stasis  of  blood,  or  of  an  energetic 
uterine  reaction. 

Active  or  sthenic  metrorrhagia,  by  general  or  local  fluxion,  or  by 
vascular  expansion,  is  accompanied  by  all  the  signs  which  characterise 
fluxionary  movements,  and  by  all  the  symptoms  of  local  congestion 
and  excitement  or  of  general  reaction  which  are  peculiar  to  this  patho- 

^  Parent-Duchatelet,  de  la  Prostitution  dans  la  ville  de  Paris,  t.  i,  p.  232, 
3«  edit.,  1857. 

22 


338  UTEEINE    DISEASES    IN  DETAIL 

logical  act :  pain^  tension,  sense  of  weight  in  the  uterus,  pain  and 
dragging  in  the  loins  and  groins,  pruritus  at  the  vulva,  painful  tume- 
faction of  the  breasts ;  shooting  neuralgic  pains  in  the  kidneys  and 
legs ;  hardness,  swelling,  extreme  sensibility  of  the  hypogastrium ; 
tumefaction,  heat,  sensitiveness,  dark  red  colour  of  the  vulva,  vagina 
and  cervix ;  a  general  excitement,  a  strong  and  rather  quick  pulse, 
followed  by  weariness,  cramp,  giddiness,  feverishness,  and  sometimes 
by  various  nervous  or  hysterical  symptoms ;  in  short,  an  exaggeration 
of  the  ordinary  symptoms  of  uterine  fluxion  as  they  occur  at  the  com- 
mencement of  menstruation.  Passive  metrorrhagia  is  asthenic.  It  is 
favoured  by  general  conditions  not  only  of  debility,  atony  and  asthenia, 
but  still  more  by  those  characterised  by  adynamia,  such  as  scorbutus 
and  other  serious  constitutional  disorders.  It  is  never  preceded  by 
premonitory  symptoms,  nor  accompanied  by  the  local  phenomena 
which  characterise  the  hsemorrhagic  molimen.  There  are  no  signs 
of  local  plethora  in  the  genital  organs;  of  the  heat,  tension 
and  arterial  pulsation  which  characterise  fluxionary  movements. 
The  pulse  is  quick,  but  small  and  compressible,  and  there  is 
a  general  chilliness  and  want  of  reaction.  The  haemorrhage, 
which  generally  occurs  suddenly  and  with  a  certain  moderation, 
continues  uninterruptedly,  sometimes  without  clots  when  the  blood 
is  serous.  The  clots  and  colics  are  to  be  met  with  in  both  kinds 
of  hsemorrhage,  but  with  shades  of  difference  which  suffice  to 
distinguish  them ;  for  instance,  the  expulsive  pains  are  less  acute 
and  less  frequent  in  passive  hsemorrhage,  whilst  active  hsemorrhage 
is  characterised  by  extreme  sensibility  or  hysteralgia  and  by  repeated 
uterine  colics. 

Treatment. — The  first  question  is  :  Should  the  hsemorrhage  in  metror- 
rhagia, or  even  in  menorrhagia  be  arrested  ?  In  the  immense  majority 
of  cases  this  may  be  answered  in  the  affirmative.  The  hsemorrhage 
becomes  injurious  whenever  it  passes  the  limits  of  menstrual  evacua- 
tion ',  for  it  is  insufficient  to  effect  depletion  of  the  organ,  it  continues 
or  recurs  indefinitely,  one  hsemorrhage  is  followed  by  another,  the 
morbid  habit  is  established,  the  constitution  deteriorates,  the  blood  is 
impoverished,  the  patient  becomes  anaemic,  and  these  conditions,  in 
place  of  being  favorable  to  the  cessation  of  the  hsemorrhage,  only 
facilitate  it  and  induce  its  return,  so  that  from  being  active  it  becomes 
passive.  Therefore  every  means  should  be  taken  to  prevent  and  arrest 
metrorrhagia. 

The  means  to  be  employed  vary  acccording  to  the  nature  of  the 
hsemorrhage.  The  indications  are  principally  drawn  from  the  active  or 
passive  character  of  the  metrorrhagia.  In  the  former  case  we  have  to 
contend  with  the  fluxionary  movement,  the  fluxion  and  even  congestion 
of  the  organ.  In  the  latter,  with  exhalation  and  exudation,  as  well  as 
with  the  general  debility  of  the  constitution  and  impoverishment  of  the 
blood.  The  indications  vary  also  according  as  the  hsemorrhage  is 
symptomatic  or  idiopathic.  In  the  former  case,  arresting  the  flow 
of  blood  is  only  a  palliative  treatment  which,  though  useful,  is  insuffi- 
cient as  it  does  not  attack  the  malady  which  causes  the  hsemorrhage ; 


UTERINE    HiEMORRHAGE  339 

in  the  latter  case^  it  is  from  the  hsemorrhage  itself  and  its  nature  that 
the  indications  are  taken. 

I  cannot  now  enumerate  the  means  of  treatment  of  the  various 
maladies  which  determine  symptomatic  hsemorrhage.  They  will  be 
described  in  connection  with  each  disease.  I  cannot  even  review  all 
the  means  of  treatment  of  the  various  pathological  elements  which 
participate  in  the  production  of  idiopathic  haemorrhages,  for  these 
various  elements  require  to  be  treated  independently  of  the  flow  of 
blood  which  they  may  produce^  but  which  they  do  not  necessarily 
cause.  I  shall  therefore  only  consider  them  from  the  point  of  view  of 
the  share  which  they  take  in  the  production  of  haemorrhage. 

Metrorrhagia,  strictly  so-called,  being  separated  from  the  maladies 
which  produce  it,  and  from  the  elements  which  co-operate  in  its  mani- 
festation, it  only  remains  for  us  to  state  the  indications  special  to  it ; 
these  are : — 1,  to  prevent  the  fluxionary  movement  from  taking  place; 
2,  to  divert  it  when  it  has  taken  place  ;  3,  to  subdue  the  congestion 
and  erethism ;  4,  to  employ  haemostatics ;  5,  to  destroy  haemorrhagi- 
parous  organic  alterations  of  the  mucous  membrane ;  6,  to  prevent 
haemorrhage  by  mechanical  obstacles ;  7,  to  treat  the  impoverishment 
of  the  blood  and  its  want  of  plasticity. 

1.  To  prevent  the  occurrence  of  the  fluxionary  movement, — This  can 
be  attained  by  the  use  of  three  means :  rest,  local  refrigeration, 
general  heat.  There  should  be  absolute  rest,  the  patient  lying  on  her 
back  with  the  thighs  and  legs  flexed,  and  supported  by  pillows,  and 
the  head  or  at  least  the  shoulders  low.  She  should  be  kept  in  this 
position,  not  rising  even  to  pass  water.  Local  refrigeration  is  obtained 
by  means  of  compresses  soaked  in  cold  water  of  the  temperature  of  the 
room  in  winter,  in  spring  water  or  ice  in  summer;  these  compresses 
should  be  applied  to  the  abdomen  and  upper  part  of  the  thighs  and 
renewed  as  they  become  warm. 

It  is  often  better  in  order  not  to  wet  the  patient,  to  substitute  for 
the  compresses  a  bladder  or  gutta-percha  bag  filled  with  pieces  of  ice 
which  can  be  renewed  as  they  melt,  or  fragments  of  ice  may  be  intro- 
duced into  the  vagina  every  quarter  of  an  hour.  General  heat  should 
be  maintained  by  blankets,  or  eider-down  quilts,  and  hot- water  bottles 
to  the  feet  and  arms.  If  necessary  sinapisms  may  be  applied  to  the 
wrists,  arms  and  even  upper  part  of  the  chest,  the  knees,  calves  and 
insteps.  Ventilation  should  also  be  attended  to.  In  all  haemorrhages 
great  care  should  be  taken  to  renew  the  air  of  the  room  frequently. 
By  these  means,  not  only  is  a  bracing  effect  produced  on  the  whole 
body,  but  a  kind  of  general  revulsion  is  effected  on  the  whole  system 
which  has  a  tendency  to  divert  the  fluxionary  movement  from  the 
uterus ;  hematosis  is  facilitated,  and  by  the  rapid  renewal  of  air  in  the 
lungs  an  activity  is  given  to  the  general  circulation  favorable  to  peri- 
pheric circulation  and  tending  to  subdue  the  disposition  of  fluxionary 
movements  to  select  one  point  in  preference  to  all  others, 

2.  To  divert  the  fluxion  hy  revulsives. — The  most  powerful  revulsive 
is  bloodletting.  It  should  be  from  the  arm  rather  than  the  foot,  for 
the  blood  should  be  diverted  from  the  lower  to  the  upper  part  of  the 


340  UTEEIlfE  DISEASES    TN    DETAIL 

body,  and  not  merely  deviated  from  the  pelvis  to  the  feet.  Blood- 
letting is  not  always  limited  to  a  revulsive  bleeding.  If  the  patient  is 
strong,  plethoric,  and  experiencing  a  movement  of  general  expansion 
or  fluxion,  copious  depletion  should  be  resorted  to.  If  she  has  not 
too  much  blood,  or  if  there  is  a  tendency  to  debility,  if  the  bleeding 
has  to  be  repeated  every  month  as  a  preventive  measure  against  a 
menorrhagia  which  threatens  to  become  habitual,  it  will  sufBce  to  take 
from  1^  to  4^  ounces  from  the  vein  according  to  Lisfranc's  method. 
"When  the  fluxion,  in  place  of  being  imminent  or  recent,  is  fixed  on 
the  organ,  derivative  applications  of  leeches  or  cupping  to  the  hypo- 
gastrium,  to  the  iliac  regions  and  loins,  will  mobilise  the  congestion 
and  advantageously  precede  the  use  of  revulsives  proper.  A  powerful 
revulsive  action  may  be  effected  in  ansemic  women  without  loss  of 
blood  by  dry  cupping  of  the  loins,  back,  thorax,  arms  or  breasts 
according  to  the  precept  of  Hippocrates. i  In  such  cases  there  is  no 
need  to  fear  the  use  of  large  cupping  glasses  acting  on  the  whole  of  a 
limb  according  to  Junod/s  method.  The  application  of  ligatures  to 
the  root  of  the  four  limbs,  according  to  Galen's  precept,  so  as  to 
congest  them  by  retaining  in  them  the  venous  blood,  is  a  very  good 
substitute  for  large  cupping  glasses,  which  are  not  always  at  hand. 
All  that  is  required  are  four  handkerchiefs  folded  like  scarfs  and  tied 
tightly  round  each  limb,  and  tightened  at  will  by  means  of  small 
sticks  passed  through  the  knot  of  the  handkerchief.  I  have  never 
had  recourse  to  this  means  in  uterine  haemorrhages,  but  it  has  been  of 
such  great  use  in  very  serious  cases  of  haemoptysis,  that  I  have  the 
greatest  confidence  in  it.  Lastly,  sinapisms  on  the  arms  are  also 
excellent  revulsives  which  should  not  be  neglected. 

If  the  fluxion  is  persistent  or  of  long  standing,  and  if  it  has  a  ten- 
dency to  be  renewed  periodically  or  to  become  chronic,  more  continuous 
revulsives  ought  to  be  employed : — blisters,  even  exutories,  or,  if  the 
patient  is  young,  hydropathy  in  the  intervals  between  the  attacks. 
Lastly,  ipecacuanha  and  antimony  as  used  by  Stoll  and  Linke  in 
metrorrhagia  when  sympathetic  of  bilious  affections,  and  emetics  gene- 
rally, may  be  useful  as  revulsives  as  well  as  means  of  perturbation. 
Ipecacuanha  in  small  doses  frequently  repeated  has  proved  very  efiica- 
cious,  probably  by  the  movement  of  expansion  which  it  determines 
towards  the  periphery. 

3.  To  subdue  the  congestion  which  foUovjs  tlie  fluxion  or  the  erethism 
which  accompanies  it. — I  have  seen  patients  in  whom  haemorrhage 
was  arrested  by  the  application  of  leeches  to  the  cervix,  after  the 
failure  of  the  majority  of  means  usually  employed.  In  these  cases 
the  haemorrhage  seemed  to  be  kept  up  by  a  painful  and  persistent 
congestion  of  the  uterus.  The  indication  is  clear;  it  must  not  be 
misunderstood,  for  no  other  means  than  direct  depletion  of  the  organ 
will  avail.  When  general  or  local  nervous  and  vascular  erethism  is 
associated  with  congestion,  sedatives,  antispasmodics  and  narcotics 
may  be  indicated.  Aran  recommends  veratrine  in  large  doses, 
Dickinson  digitalis,  Behier  opium  by  the  mouth  or  laudanum  in  rectal 
'  Ti-anslation  by  Littre,  Aphorism  50,  Section  v,  t.  iv,  p.  551. 


UTERINE    HiEMOREHAGE  341 

injections.  The  progress  of  the  haemorrhage  must  however  be 
watchedj  care  being  taken  that  time  is  not  lost  in  the  use  of  remedies 
which  produce  no  effect.  It  is  difficult  to  know  whether  the  warm 
bath  acts  as  a  sedative  or  as  a  general  revulsive  in  the  treatment  of 
metrorrhagia ;  but  there  is  no  doubt  that  in  some  cases  it  is  sufficient 
to  arrest  the  haemorrhage.  Unfortunately  we  have  not  yet  been  able 
to  determine  when  this  treatment  is  indicated.  Heat  applied  to  the 
loins  often  does  great  good,  and  can  never  do  harm.  To  sum  up 
what  we  know  with  regard  to  this  subject,  we  must  be  content  to  say 
that  the  application  of  heat  to  the  lumbar  region  according  to  Chap- 
man's plan  (the  application  of  an  india-rubber  bag  filled  with  water  as 
hot  as  the  patient  can  bear),  in  order  to  stimulate  the  vaso-motor 
action  of  the  sympathetic  ganglia,  has  succeeded  with  de  Mussy,^ 
Cusco  and  myself.  So,  too,  has  the  application  of  heat  to  the  uterus 
and  vagina.  A  vaginal  injection  of  water  as  hot  as  can  be  borne  (as 
a  rule,  45°  centigrade)  is  often  the  best  way  of  preventing  or  stopping 
uterine  haemorrhage.  Like  Emmet  I  have  tried  these  injections 
repeatedly  and  found  them  to  have  an  excellent  haemostatic  effect 
{Annates  de  Gynecologie  de  Paris,  mai,  1880).  Experience  has 
proved  the  use  of  digitalis  as  an  additional  sedative  of  the  vascular 
system ;  by  lessening  the  frequency  of  the  pulse,  it  diminishes  the 
impulse  by  which  the  blood  is  incessantly  accumulated  in  the  con- 
gested organ. 

4.  The  use  of  hamostatics,  strictly/  so  called,  astringents,  styptics^ 
and  coagulants. — These  means  are  especially  indicated  in  the  treat- 
ment of  passive  metrorrhagia  when  there  is  exudation  as  well  as  im- 
poverishment of  blood  and  general  debility ;  they  are  also  very  often 
indicated  in  the  palliative  treatment  of  symptomatic  metrorrhagia. 
The  local  application  of  cold  to  the  hypogastrium  by  a  bladder  filled 
with  ice,  cold  compresses,  enemata,  sitz-baths,  vaginal  plugging 
with  ice,  should  be  made  continuously.  The  most  convenient  plan  is 
for  the  patient  herself  to  introduce  ice  frequently  into  the  vagina,  the 
water  discharged  being  received  by  a  sponge  placed  under  the  four- 
chette  in  a  piece  of  waterproof.  Acids  and  astringents  should  be 
taken  internally.  Those  most  employed  are :  vinegar  and  water,  or  a 
few  drops  of  dilute  sulphuric  acid  in  a  glass  of  lemonade,  a  spoonful 
of  which  may  be  taken  every  quarter  of  an  hour.  This  simple  means 
is  often  very  successful.  Tincture  of  cinnamon,  as  advised  by  Van 
Swieten,  the  Germans,  Recamier,  Gosselin  and  Aran  (from  1|  to  5 
drachms  in  four  ounces  of  water,  of  which  one  tablespoonful  every 
hour),  alum,  acetate  of  lead,  catechu,  tannic  acid,  and  especially 
rhatany,  are  recommended,  as  in  all  haemorrhages.  The  extract  of 
rhatany,  given  in  an  enema  (15  gv.  to  one  quart),  or  in  mixture 
(H.  Ext.  Ehat.  3j,  Syr.  Aurant.  3j,  Aq.  ^iv.  Sig.  ^ss  every  two 
hours),  is  one  of  the  most  efficacious  and  the  least  dangerous  of 
astringents.2     I  have  often  tried  perchloride  of  iron,  but  do  not  trust 

'  Annales  de  Gynecologie  de  Paris,  July,  1875. 

^  I  often  give  the  following  prescription  : — Infuse  4^  gr.  of  digitalis  leaves 
in  4  oz.  of  water.     Add   1  oz.  of  syrup  of  comfrey,  5  drachms  of  syrup  of 


342  UTERINE   DISEASES    IN    DETAIL 

to  it.  If  indicated  by  impoverishment  of  blood,  ansemia,  or  a  scor- 
butic condition,  it  should  be  prescribed  in  the  dose  of  from  15  minims 
to  5J  in  a  glass  of  water,  of  which  one  tablespoonful  should  be  taken 
every  two  hours,  followed  by  cold  milk  to  remove  the  disagreeable 
sensation  left  in  the  throat.  In  chronic  metrorrhagia  with  chloro- 
angemia  I  give  from  5  to  15  drops  morning  and  evening  in  water 
followed  by  a  glass  of  milk.  It  may  also  be  applied  directly  to  the 
uterine  mucous  membrane.  Weber,  of  St.  Petersburg,  injects  a 
solution  into  the  uterine  cavity.  I  have  done  the  same,  commencing 
with  small  quantities,  and  trying  to  avoid  the  formation  of  clots, 
the  expulsion  of  which  would  be  painful  and  might  cause  additional 
hgemorrhage.  I  prefer  the  use  of  the  tincture  of  iodine.  Uterine 
specifics,  i.  e.  drugs  which  have  the  property  of  exciting  uterine  con- 
traction as  well  as  of  favouring  hemastasis,  are  employed  along  with 
the  preceding  in  the  treatment  of  metrorrhagia,  e.ff.  savin  and  ergot, 
the  latter  especially.  I  generally  prescribe  4  grains  every  six  hours, 
or  if  necessary  every  three  hours,  in  a  little  coffee  or  brandy  or  sugar 
and  water.  When  the  action  has  to  be  kept  up  for  some  time  I  use 
ergotine  instead.^  The  application  of  electricity  to  the  uterus,  by 
inducing  contractions  of  the  tissue,  is  a  valuable  adjuvant  of  ergot, 
especially  when  the  latter  is  not  tolerated ;  the  interrnpted  current 
should  be  used. 

5,  To  destroy  the  organic  alterations  hy  which  the  discharge  of  Mood 
is  produced,  and  to  modify  the  state  of  the  mucous  membrane  in  which 
these  alterations  are  developed. — Eecamier^s  curette  renders  great 
services  in  such  cases.  I  have  had  a  broader  one  made,  and  also  two 
others  of  a  different  pattern  {see  p.  225),  and  with  these  instruments 
can  remove  fungosities  however  large  they  may  be,  and  even  small 
polypiform  excrescences.  There  are  hsemorrhages  that  can  be  arrested 
in  no  other  way.  It  is  sometimes  necessary  to  dilate  the  uterine 
orifice  by  sponge  tents  before  introducing  the  curette.  After  such 
operations,  local  hemastatics  or  caustics  ought  almost  always  to  be 
applied  to  the  uterine  mucous  membrane  and  cavity  by  means  of  in- 
jections.^ I  often  use  a  cameFs-hair  brush  saturated  with  tincture  of 
iodine  or  perchloride  of  iron,  or  rolled  in  the  powder  of  nitrate  of 
silver,  in  place  of  injections ;  sometimes  I  inject  a  piece  of  solid 
caustic  by  means  of  a  canula  with  piston  {see  p.  222).  The  medica- 
ments most  commonly  used  as  injections  to  modify  the  mucous  mem- 
ether,  and  5  draclims  of  tincture  of  cinnamon,  1  drachm  of  extract  of  rhatany, 
15  gr.  of  Bonjean's  ergotine,  and  14  gr.  of  extract  of  opium.  Shake  the 
bottle  and  take  one  dessert  spoonful  every  six,  or  if  necessary  every  four 
hours. 

1  The  hypodermic  injection  of  ergotine  is  very  convenient ;  the  usual  formula 
is  15  gr.  of  ergotine  (Bonjean)  dissolved  in  100  minims  of  pure  glycerine  and 
5ij  of  distilled  water.  Two  Pravaz  syringes  are  filled  and  injected :  \  gr.  to 
\\  gr.  of  ergotine  will  arrest  h£emorrhage  in  a  few  minutes.  Doubtless  the 
haemorrhage  often  occurs  again ;  the  ■  hemastasis  is  only  temporary,  but  even 
that  is  a  great  gain. 

2  Real,  Theses  de  Paris,  1852 ;  Dupierris,  Gazette  des  hopitaux,  1869 ; 
Guyot,  Theses  de  Paris,  1868. 


CHANGES    OP   POSITION  343 

membrane  are  :  alum,  tannin,  perchloride  of  iron,  tincture  of  iodine, 
or  a  concentrated  solution  of  nitrate  of  silver. 

6.  To  prevent  the  discharge  of  blood  by  a  mechanical  obstacle  is  the 
last  and  often  the  first  means  to  which  the  continuance  or  violence  of 
the  hsemorrhage  obliges  us  to  resort ;  a  heroic  means  the  use  of  which 
must  not  be  neglected  whilst  there  is  yet  time.  This  means  is  plug- 
ging. It  must  be  preceded  by  an  iced  injection  of  solution  of  alum, 
and  by  the  application  to  the  uterus  of  a  pledget  of  lint  saturated  with 
tincture  of  perchloride  of  iron  or  charged  with  a  hemastatic  powder ; 
the  vagina  is  then  filled  with  cotton  wool,  the  last  tampon  being  kept 
in  place  by  a  T  bandage.  There  is  nothing  further  to  do  than  to 
watch  lest  the  hsemorrhage  which  has  been  arrested  in  the  vagina 
should  take  place  internally,  distending  the  uterus  and  passing  along 
the  Fallopian  tubes.  Should  this  occur,  which  rarely  happens,  the 
plugging  must  be  renewed,  and  the  other  means  previously  described 
must  be  once  more  employed  with  increased  energy. 

In  cases  of  hsemorrhage  kept  up  by  uterine  inertia,  in  thin  women 
in  whom  the  abdominal  parietes  are  easily  depressed,  I  should  be  in- 
clined to  try  compression  of  the  aorta  before  plugging.  I  do  not 
understand  the  objections  which  have  been  made  to  this  method.  I 
have  seen  two  women  saved  by  it  after  delivery :  the  aorta  was  com- 
pressed by  the  midwife  or  myself  for  three  hours,  during  which  time, 
by  emptying  the  uterus  of  clots,  by  irritating  the  cervix,  by  grasping 
the  fundus  and  administering  ergot  I  succeeded  in  getting  the  womb 
to  contract,  and  was  rewarded  by  the  formation  above  the  pubis  of 
the  hard  reassuring  uterine  globe. 

7.  To  treat  the  dehility  and  impoverishment  of  blood  ivhich  dispose 
to  hemorrhage  by  the  defective  plasticity  of  this  fluid  and  by    the 

facility  given  to  the  production  offluxionary  movements  or  passive  con- 
gestions by  defective  equilibrium.  Whatever  the  nature  of  the  hsemor- 
rhage may  be,  care  must  be  taken  to  prevent  its  return  by  using  means 
to  prevent  fluxion,  to  increase  the  plasticity  of  the  blood,  to  give  tone 
to  the  vessels,  to  strengthen  the  constitution  by  a  good  regimen, 
tonics,  bark,  iron,  &c.  We  must  prevent  relapses  as  in  all  uterine 
diseases,  remembering  that  we  can  only  be  sure  that  a  cure  has  been 
effected  after  the  recurrence  of  several  normal  and  regular  monthly 
periods. 


CHAPTER  II 

CHANGES   OF    POSITION — DISPLACEMENTS — DEVIATIONS — FLEXIONS — INVERSION 

With  the  exception  of  cases  of  hernia,  prolapsus^  retroflexion, 
complete  retroversion  and  inversion,  simple  changes  of  position  very 
seldom  determine  the  development  of  serious  morbid  symptoms.  They 
deserve  attention,  however,  owing  to  the  complications  which  precede, 
accompany  or  follow  them,  and  which  are  sometimes  the  chief  cause 
of  the  pains  felt.     These  maladies  are  not  only  mechanical  lesions. 


344  UTEEINE    DISEASES    IN   DETAIL 

they  may  be  designated :  diseases  in  which  an  alteration  of  the 
mechanical  conditions  of  the  uterus  plays  the  principal  part,  causing 
a  disturbance  in  the  relationship  of  this  organ  with  neighbouring 
organs.  This  disturbance  may  occur  in  three  ways  according  as  it 
may  affect :  1,  the  means  of  suspension  (utero-sacral  ligaments)  which 
form  a  suspensory  ring  for  the  organ^  ensuring  its  fixity  of  position 
in  the  pelvis  at  a  certain  height ;  2^  the  supports  direct  or  indirect 
(broad  and  round  ligaments,  vaginal  attachments,  pelvic  connective 
tissue),  which  keep  the  longitudinal  axis  of  the  uterus  in  the  normal 
median  inclination,  whilst  allowing  divergences  which  its  natural  in- 
difference for  a  fixed  position  renders  compatible  with  health  ;  3,  the 
consistency  of  the  uterine  tissue,  the  relative  dimensions  of  the  walls 
and  borders,  the  reciprocal  relations  of  the  two  segments  (body  and 
neck)  which  determine  the  preservation  of  the  normal  form  of  the 
organ,  and  the  natural  relations  of  the  various  parts  with  each  other. 
According  to  these  three  modes  of  origin  the  primitive  alteration  leads 
to  a  secondary  one:  1,  in  the  position  of  the  organ;  2,  in  its  abso- 
lute direction  and  its  relations  with  neighbouring  organs ;  3,  in  the 
relative  direction  or  the  reciprocal  relations  of  its  two  segments.  In 
the  first  case  this  secondary  alteration  takes  the  name  of  displacement, 
in  the  second  that  of  deviation,  in  the  third  that  q{ flexion. 

1.  Displacements  of  the  uterus  are,  therefore,  changes  in  the 
positio7i  of  this  organ.  The  womb,  not  being  properly  retained  in 
place  by  its  suspensory  ring,  or  yielding  to  the  pressure  or  traction 
exercised  by  a  neighbouring  organ,  abandons  its  proper  place.  It 
escapes  partially  or  entirely  from  the  pelvic  cavity  by  a  subcutaneous 
opening,  and  forms  a  hernia  under  the  skin  {hysterocele) ,  or  it  remains 
in  this  cavity,  but  at  a  difi'erent  spot  from  its  natural  position,  giving 
rise  to  displacements  properly  so  called,  horizontal  or  vertical,  the 
most  important  of  which  is  descent  {prolapsus').  Hernise  of  the 
ovary  and  Pallopian  tubes  are  analogous  displacements,  and  will  be 
described  at  the  same  time  as  those  of  the  uterus. 

2.  Deviations  are  changes  of  direction  of  the  uterus  as  a  whole,  or 
displacements  of  the  vertical  axis  of  the  organ,  independent  of  those 
of  its  suspensory  ring,  the  latter  either  preserving  its  normal  position 
or  not.  They  vary  in  degree,  from  the  slightest  inchnation  to  the 
most  complete  version. 

3.  Flexions  are  alterations  in  the  form  of  the  organ  owing  to  a 
change  of  direction  of  one  portion  with  regard  to  the  other.  The 
organ  as  a  whole  may  or  may  not  preserve  its  normal  position  and 
direction.  It  follows  that  flexions  may  either  exist  alone  or  coincide 
with  displacements  and  deviations.  They  sometimes  coincide  with 
another  change  of  direction,  which  it  is  interesting  to  take  into 
account,  viz.  deviation  of  tTie  transverse  axis.  This  axis  turns  slightly 
sometimes  to  one  side  sometimes  to  the  other,  so  that  the  anterior 
surface  of  the  uterus,  instead  of  looking  straight  forwards,  looks 
forwards  and  to  the  right  or  forwards  and  to  the  left.  This  deviation 
is  of  little  consequence  when  both  segments  of  the  womb  are  equally 
affected,  but  if  the  deviation  affects  them  unequally  there  is  torsion, 


CHANGES    OF    POSITION  345 

which  may  cause  other  symptoms^  and  be  the  source  of  special  indica- 
tions. 

4.  Lastly,  inversion  is  another  mode  in  which  the  statical  conditions 
of  the  uterus  may  be  altered.  Cruveilhier  compared  it  to  prolapsus,  in 
common  with  which  it  has  the  anatomical  characteristic  of  invagina- 
tion, whilst,  in  common  with  flexions,  it  has  a  change  in  the  mutual 
position  of  the  various  parts  of  the  uterus  with  regard  to  each  other. 
It  is  characterised  also  by  a  change  in  the  reciprocal  relations  of  its 
two  surfaces,  the  internal  surface  gradually  becoming  external  and 
convex,  whilst  the  external  becomes  internal  and  concave.  It  follows 
that  the  organ  is  in  a  sense  turned  inside  out,  like  the  finger  of  a 
glove. 

With  the  exception  of  inversion,  which  is  essentially  a  morbid  con- 
dition, and  prolapsus,  which  involves  destruction  of  the  suspensory 
attachments  of  the  womb,  all  the  different  changes  of  position  (dis- 
placement, deviation,  torsion,  flexion)  may  occur  in  foetal  life  which, 
representing  a  certain  period  in  the  development  of  the  genital  organs, 
or  rather  a  stage  in  the  progressive  changes  in  their  position  in  the 
pelvis,  can  only  be  explained  by  the  influence  exercised  on  them  by 
the  normal  or  abnormal  evolution  of  the  neighbouring  organs. 

Ereund,^  in  a  recent  work  on  the  development  and  changes  in 
position  of  the  rectum,  bladder  and  genital  canal  from  the  sixth  week 
of  foetal  life  up  till  birth,  shows  that  the  changes  in  position  brought 
about  by  organic  evolution  simultaneously  in  the  rectum  and  bladder, 
cause  inverse  changes  in  the  uterus;  that  the  distension  of  the  rectum 
by  the  meconium  and  that  of  the  bladder  by  the  urine  exercise  an 
important  influence  upon  the  elevation  of  this  organ.  Lastly,  that  the 
descent  of  the  intestinal  convolutions  into  the  pelvis,  the  daily  evacua- 
tions of  rectum  and  bladder,  and  the  increased  size  of  the  pelvic 
cavity,  notify  a  period  of  restitution  or  return,  during  which  the 
uterus  is  liberated  from  the  temporary  changes  in  position  which  the 
development  of  the  pelvic  organs  had  imposed  upon  it.  These 
changes,  however,  may  become  permanent ;  normal  at  one  period, 
they  sometimes  persist  as  anomahes.  The  pelvic  organs  themselves 
may  be  developed  abnormally,  new  alterations  in  the  natural  position 
of  the  uterus  may  be  produced,  and  may  persist  and  constitute  so 
many  pathological  elements  new  in  the  history  of  the  changes  in 
position  of  the  uterus.  These  changes  are  met  with  in  about  one 
third  of  the  patients  affected  with  uterine  disease,  either  constituting 
a  disease  in  themselves  or  complicating  some  other  malady  or  organic 
disorder.  They  occur,  I  think,  less  frequently  in  the  south  of  France 
than  in  the  north,  especially  prolapsus.  As  to  relative  frequency, 
anteflexions  and  anteversions^  are  much  the  most  numerous;  then 
come  retroflexions  and  retroversions ;  then  prolapsus,  and  lastly, 
lateroversions  and  lateroflexions,  double  incurvations,  torsions,  dis- 
placements of  the  organ  as  a  whole,  either  forwards,  backwards  or 

^  Max  Bernhard  Freund,  Die  Lageentwlckelung  der  Beclcenorgane  xmsbeson- 
dere  des  loeiblichen  Genitalcaaals  und  ihre  Ahivege.     Breslau,  186'1. 
^  See  pi^.  17,  23. 


346  UTERINE    DISEASES    IN    DETAIL 

laterally.     Inversions  are  rarest  of  all,  with  the  exception  of  hernia  of 
the  uterus  and  ovaries. 


Displacements 

The  importance  of  displacements  of  the  uterus,  from  a  practical 
point  of  view,  depends  on  whether  they  are  simple  or  compHcated. 
Ascent,  descent  and  horizontal  displacements,  such  as  lateral  position 
or  lateral  migration  and  even  antero-posterior  migration  may  generally 
be  ranked  as  simple  displacements.  Whilst,  on  the  contrary,  cases 
of  hernia  and  prolapsus  must  be  considered  as  complicated  dis- 
placements. 

1.  Hernia  of  the  Ovaries  and  Fallopian  Tubes 

This  is  sometimes  produced  by  an  alteration  affecting  the  organs 
themselves,  sometimes  by  displacements  of  the  uterus  or  changes  in  it. 

I.  Hernia  of  the  ovary  is  not  the  only  displacement  of  this  organ. 
Congestion  or  inflammation  may  increase  the  size  and  weight  of  the 
ovary  and  cause  its  displacement  into  the  pelvis,  especially  descent 
either  laterally  or  behind  the  uterus.^  This  displacement  is  easily  dis- 
covered by  rectal  and  even  by  vaginal  touch,  as  well  as  by  the  increased 
size  and  sensibility  of  the  ovary.  Its  pathological  sensibility  is  de- 
veloped to  such  an  extent,  that  the  least  pressure  produces  intense 
pain. — On  the  other  hand,  when  the  ovaries  are  merely  dragged  by 
a  deviated  or  flexed  uterus,  it  is  seldom  that  this  displacement  is  not 
at  last  complicated  by  congestion  of  these  organs.  Lastly,  when  the 
displacement  coincides  with  ovarian  inflammation  the  phlegmasia 
often  extends  to  the  peritoneum,  especially  if  the  ovary,  Fallopian 
tube  and  uterus  are  affected  simultaneously.  Peritonitis  generally 
leaves  vicious  adhesions  between  the  ovaries  and  neighbouring  organs. 
These  adhesions,  by  rendering  displacements  of  the  ovaries  permanent, 
form,  according  to  Madame  Boivin,  one  of  the  most  frequent  and 
least  known  causes  of  abortion.  They  attach  the  ovary  sometimes  to 
the  Fallopian  tube  or  to  the  uterus  (which  causes  sterility),  sometimes 
to  the  csecum,  to  the  colon,  to  the  sigmoid  flexure,  to  the  rectum  or 
to  the  walls  of  the  pelvis.^ 

Hernise  of  the  ovary  are  displacements  outside  the  pelvis,  which 
occur  less  frequently  than  the  preceding,  but  yet  oftener  than  is 
generally  believed.  The  first  detailed  case  was  published  in  the 
seventeenth  century  by  Bessiere,  a  surgeon  in  Paris.  Deneux^  wrote 
an  interesting  paper  on  this  subject  in  the  beginning  of  this  century. 
Velpeau*  described  this  disease  under  the  name  of  ovarioncie.     Several 

^  Braun  lias  described  some  of  these  displacements  under  the  name  of 
ovario-vaginal  hernia  {Monatsschrift  fur  Gehtirts'k.,  Bd.  xiv,  S.  472). 

^  Barnes  gives  a  very  practical  resume  of  the  principal  causes  of  displace- 
ments of  the  ovary,  op.  cit.,  p.  297. 

^  Becherches  sur  la  hemic  de  I'ovaire.  Paris,  1813. 

^  Dictionn.  en  30  vol.,  t.  xxii,  p.  558.  Paris,  1840. 


DISPLACEMENTS  347 

new  cases  have  been  recently  published.^  I  have  myself  seen  five 
cases  of  ovarian  hernia :  a  right  inguinal  hernia,  reducible,  in  a  child 
of  ten  (probably  congenital)  ;  a  right  crural  hernia,  irreducible,  in  a 
virgin  of  forty,  which  sometimes  swelled  and  became  painful  at  the 
monthly  period,  and  was  at  one  time  attacked  by  inflammation,  when 
it  developed  symptoms  of  stricture,  which  yielded  to  antiphlogistics 
and  purgatives ;  a  right  crural  hernia  in  a  woman  of  forty-two,  who 
assured  me  that  the  tumour,  which  had  existed  for  fifteen  years, 
became  painful  and  larger  at  every  monthly  period ;  she  succumbed 
to  symptoms  of  stricture  and  peritonitis,  the  slow  progress  of  which 
(about  fifteen  days)  would  have  allowed  of  her  being  saved,  had  she 
not  obstinately  refused  any  kind  of  operation ;  a  left  crural  hernia  in 
a  nullipara  of  fifty,  who  had  ceased  menstruating  for  four  years,  and 
who  remembered  having  sometimes  experienced  pains  in  the  tumour 
during  menstruation  ;  she  had  worn  an  elastic  bandage  for  twenty- 
five  y.ears  to  contain  the  hernia,  the  nature  of  which  had  probably 
been  misunderstood  j  a  left  inguinal  hernia,  probably  congenital,  in  a 
virgin  of  twenty-six,  forming  in  the  groin  a  tumour  very  sensitive  to 
the  touch,  very  painful  and  larger  at  every  monthly  period,  and  which 
coincided  with  a  marked  obhquity  of  the  uterus,  the  cervix  of  which 
looked  backwards  and  to  the  right ;  the  puffiness  of  the  tumour  led 
to  the  supposition  that  the  Eallopian  tube  shared  in  the  displacement ; 
a  bandage  tried  for  some  months  had  to  be  abandoned,  on  account  of 
the  pain  that  it  caused. 

Inguinal  ovarian  hernia  is  more  frequent  than  crural  in  newly-born 
children,  and  indeed  at  every  age,  contrary  to  what  we  might  expect, 
the  reverse  generally  being  the  case  with  intestinal  hernise  in  women. — 
According  to  Deneux  crural  is  to  inguinal  in  the  proportion  of  one 
to  nine,  according  to  Murat  two  to  nine. — The  iscJiiaiic  or  dorsal  has 
been  described  by  Papeu,^  who  discovered  in  a  hernia  the  presence 
simultaneously  of  the  intestine  and  right  ovary;  Camper,  in  1759, 
found  one,  in  the  sac  of  which  the  left  ovary  alone  was  contained. — 
Umbilical  ovarioncia  may  occur  in  cases  of  pregnancy  or  of  any  uterine 
disorders  sufiicient  to  cause  displacement  of  the  ovaries  towards  the 
umbilicus. 

Ovarian  hernia  may  be  simple  or  double.  In  the  latter  case  it 
may  occur  on  both  sides  at  once,  through  the  corresponding  openings, 
as  in  Pottos  case,^  where  both  ovaries  were  removed ;  or  tlirough 
different  openings,  such  as  the  umbilical  and  ischiatic,  as  in  Camper's 
case.  According  to  the  statistics  of  Puech,  completed  since  the  pub- 
lication of  his  paper,^  there  are  on  record  8£  cases  of  inguinal  hernia, 
12  of  crural,  £  of  ischiatic,  3  of  abdominal  (the  results  of  abscess  or 
of  Caesarian  operation),  and  1  through  the  foramen  ovale  (Kiwisch) ; 
but  of  the  8;'-  inguinal  50  are  undoubtedly  congenital,  IG  doubtful, 
16  really  accidental.     Congenital   hernia  has  been  found  twenty-six 

1  Loumaigne,  De  la  hernie  cle  I'ovaire.  Paris,  1869. 
^  Haller,  Disputationes  cldrur.,  1750. 
3  Pott's  Works,  vol.  iii,  p.  329.  London,  1783. 
^  Des  ovaires,  cle  leurs  anomalies.  Paris,  1873. 


348  UTEEINE    DISEASES    IN    DETAIL 

times  unilateral,  twenty-four  times  bilateral  or  double. — They  are 
often  complicated  by  malformations  of  the  genital  organs,  e.  g.  accom- 
panied four  times  with  uterus  unicornis  or  bicornis,  fourteen  times 
with  hermaphrodism,  sixteen  times  with  apparent  or  real  absence  of 
the  uterus. 

Erom  an  analysis  of  the  cases  just  mentioned  we  may  conclude  that 
ovarian  hernia  belong  to  two  quite  distinct  classes  :  1,  congenital 
hernise,  always  inguinal,  often  double,  and  when  single  generally  left, 
caused  by  an  abnormal  descent  of  the  ovaries  analogous  to  the  normal 
descent  of  the  testicles,  constituting  anomalies  rather  than  diseases, 
and  coinciding  usually  with  anomalies  of  the  genital  organs,  such  as 
embryonic  uterus,  uterus  unicornis,  hermaphrodism,  &c. ;  2,  hernise 
properly  so  called,  accidental  and  morbid,  right  or  left  indifferently, 
inguinal  or  crural,  oftener  crural,  frequently  following  an  intestinal 
hernia,  in  which  case  the  ovary  may  occupy  the  sac  either  alone  or 
simultaneously  with  the  intestine,  epiploon,  &c.,  occurring  in  well- 
formed  adult  women. ^ 

If  congenital  hernia  is  inguinal  it  is  because  the  persistence  of 
Nuck's  canal  favours  its  production.  Lassus^  gives  an  example.  If 
accidental  hernia,  on  the  contrary,  seems  to  be  more  often  crural,  it 
is  because,  like  intestinal  hernia,  it  takes  place  through  the  abdo- 
minal opening  which  is  the  widest  in  women. 

Ovarian  hernia  when  congenital  and  observed  in  early  life  generally 
contains  only  the  ovary  ;  it  may  be  the  same  in  the  adult ;  but  in  old 
hernise  the  ovary  has  sometimes  dragged  down  with  it  the  Fallopian 
tubes,  the  uterus,  the  vagina,  and  the  intestine.  When  a  hernia  of 
long  standing  is  complex,  it  seems  to  be  because  the  ovary  has  carried 
with  it  the  Fallopian  tube  and  even  the  uterus ;  for  by  the  fact  of  its 
displacement  the  ovary  drags  the  womb  to  the  side  of  the  herniary 
tumour;  the  uterus  then  executes  two  distinct  movements,  a  swinging 
one,  by  which  its  fundus  is  inclined  forwards,  and  another  of  rotation, 
which  directs  its  posterior  surface  towards  the  side  of  the  displace- 
ment ;  one  of  its  angles  is  then  turned  towards  the  ring  through  which 
the  ovary  has  passed ;  the  intestine  presses  and  increases  the  uterine 
deviation,  tending  to  complicate  the  ovarian  hernia  with  that  of  the 
Fallopian  tube  and  even  with  the  uterus.  Ovarioncia  is  very  seldom 
complicated  with  enterocele.  Lastly,  ovarian  hernia  may  be  reducible 
or  irreducible.  Its  irreducibility  may  depend  on  increased  size, 
adhesions  or  strangulation. 

II.  Hernia  of  the  Fallopian  tube  may  be  produced,  according  to 
Nelaton,'^  by  ovarian  hernia.  The  oviduct  very  rarely  escapes  through 
one  of  the  abdominal  orifices  by  itself.  Such  a  case,  however,  has 
been  described  by  Scholler :  a  little  girl,  who  died  three  weeks  after 

^  Puech,  who  has  collected  the  greatest  number  of  cases  of  ovarian  hernia, 
thinks  that  a  radical  distinction  should  be  made  between  these  two  kinds  ;  he 
therefore  proposes  that  congenital  ovarian  hernia  should  be  called  inguinal 
ectopia. 

^  Med.  oper.,  t.  i,  p.  211.  Paris,  an  iii. 

3  Patholog.  externe,  t.  iv,  p.  440.  Paris,  1857. 


DISPLACEMENTS  349 

birth,  had  a  tumour  in  the  right  inguinal  region,  which  reached  as  far 
as  the  labium,  and  contained  the  Eallopian  tube,  red  and  swollen,  but 
without  adhesions.  The  round  ligament  of  the  same  side  was  shorter 
than  the  other.  The  uterus  was  slightly  displaced,  its  axis  not  being 
parallel  with  that  of  the  body. 

Diagnosis. — This  is  drawn  from  the  following  data :  at  the  groin, 
in  the  direction  of  the  principal  axis,  or  in  the  labium,  or  even  below 
the  crural  arch,  there  is  a  small  ovoid  tumour,  circumscribed,  painful, 
dull  on  percussion,  reduced  with  difficulty  and  rarely  spontaneously, 
always  without  gurgling  although  slightly  indented,  of  a  dense  homo- 
geneous consistency,  not  easily  detached  from  the  soft  parts;  if  we 
pull  it,  so  as  to  increase  the  displacement,  we  perceive  behind  it  a 
flattened  fibrous  cord  passing  through  the  ring.  The  pain  is  increased 
by  pressure,  by  dorsal  decubitus  or  by  lateral  decubitus  on  the  oppo- 
site side  from  the  hernia  (Seller),  by  the  movements  of  the  legs,  by 
stooping  and  rising  again,  so  much  so  as  to  cause  limping  (Guersant) 
and  to  make  all  work  impossible  (Imbert,  Percival-Pott,  &c.) ;  it  is 
also  aggravated  by  pressure  on  the  hypogastrium,  by  pushing  the 
fundus  of  the  uterus  from  the  seat  of  the  hernia,  or  drawing  the 
cervix  near  it  with  the  finger  (Lassus) ;  it  is  propagated  into  the 
pelvis  and  loins  by  a  very  painful  sensation  of  dragging ;  it  extends 
from  the  seat  of  the  hernia  to  the  uterus  and  if,  with  the  end  of  the 
finger  introduced  into  the  vagina  or  rectum  a  considerable  movement  is 
conveyed  to  the  womb  from  the  side  opposite  to  that  of  the  tumour, 
this  movement  is  transmitted  to  the  contents  of  the  hernia  (Lassus). 
This  movement  should  be  made  suddenly,  and  is  aided  by  pressure  on 
the  hypogastrium  from  the  other  hand,  or  better  still  by  means  of  the 
uterine  sound,^  which  acts  simultaneously  on  the  whole  of  the  uterus 
and  at  the  same  time  reveals  the  inclination  of  the  fundus  of  the  organ 
towards  the  hernia ;  it  is  well  for  an  assistant  to  place  his  fingers  on 
the  tumour  in  order  to  judge  of  the  amount  of  movement  communi- 
cated ;  similar  movements  cannot  be  transmitted  to  an  enterocele 
(Loumaigne^s  case).^  Pain  which  is  absent  in  some  patients  and  in  a 
state  of  rest  or  in  the  intercalary  period,  is  developed  on  the  contrary 
by  exertion,  the  advent  of  menstruation,  coitus,  &c.  ;^  it  increases  also 
with  the  size  of  the  organ  at  puberty,  at  every  menstrual  period,  during 
ge^tation  and  by  taxis;  it  may  increase  to  such  an  extent  as  to  be 
symptomatic  of  strangulation. 

Although  these  symptoms  would  seem  sufficient  for  distinguishing 
between  an  ovarioncia  and  an  intestinal  or  epiploic  hernia,  an  abscess  of 
the  groin,  a  lymphatic  tumour,  &c.,  many  mistakes  have  been  made. 
Inflammation,  atrophy,  cystic,  cancerous  or  tubercular  degeneration 
of  the  ovaries,  are  sometimes  met  with  simultaneously  and  increase 
the   difficulties  of  diagnosis.     We    must   also    remember  that,   even 

'  Huguier,  Traitc  de  VhystdroTnetrie,  p.  202.  Paris,  18G5. 

^  When  digital  touch  cannot  be  practlsecl,  owing  to  absence  of  the  uterus  or 
in  the  case  oi:  children,  examination  must  be  made  througli  the  bladder  and  by- 
rectal  touch. 

^  In  ovarian  hernia,  coitus  becomes  sometimes  so  painful  tliat  marital  inter- 
course is  impossible.     Beigel  gives  instances  of  this  (op.  cit.,  t.  i,  p.  \'M)). 


350  UTEEINE    DISEASES    IN  DETAIL 

when  inguinal  hernia  is  double,  it  is  no  obstacle  to  menstruation,  and 
that  while  it  may  cause  sterility  (when  the  ovary  is  not  accompanied 
by  the  Fallopian  tube  in  the  common  hernial  sac),  it  does  not  abso- 
lutely prevent  uterine  pregnancy,  and  that  it  frequently  predisposes  to 
extra-uterine  pregnancy.^ 

Treatment. — This  consists  in  reducing  the  ovarian  tumour  and  in 
keeping  it  reduced.  It  is  easily  done  when  the  hernia  is  recent  and 
when  the  ovary  is  not  adherent  to  the  sac.  As  a  rule,  however,  after 
a  short  time  the  tumour  ceases  to  be  reducible.  In  such  cases  it  must 
be  protected  from  blows  and  from  friction  by  a  suitable  bandage,  e.g. 
a  truss  with  a  concave  cushion. 

When  symptoms  of  strangulation  are  developed  the  patient  should 
be  kept  in  a  position  of  semi-flexion,  and  leeches,  poultices  and  emol- 
lient or  narcotic  fomentations  should  be  applied  over  the  tumour. 
If  the  strangulation  persists  an  operation  is  indicated,^  i.  e.  the  ring 
which  produces  it  must  be  incised ;  for  it  is  enough  to  cause  death.  I 
have  seen  a  woman  affected  with  crural  hernia  of  the  right  ovary  suc- 
cumb to  peritonitis  as  a  consequence  of  strangulation  of  the  hernia. 
The  ovary  can  seldom  be  reduced  after  incision ;  it  will  be  found  too 
adherent  to  the  internal  surface  of  the  sac.  The  adhesions  must  first 
be  destroyed  and  reduction  made  afterwards,  or  else  we  must  imitate 
Lassus,  and  after  having  incised  the  ring  apply  emollient  applications 
to  the  ovary,  dress  it  simply,  and  when  the  inflammation  has  passed 
exercise  moderate  and  methodic  pressure. 

If  the  ovary  is  degenerated,  cancerous  or  transformed  into  a  mul- 
tilocular  cyst,  it  should  be  removed.  In  some  cases,  as  in  that  of 
Pott,  the  operation  has  not  been  followed  by  any  accident.  In  Pott's^ 
case  there  was  double  inguinal  ovarian  hernia  in  a  woman  of  twenty - 
three  -,  the  removal  of  both  ovaries  was  followed  by  cure,  but  men- 
struation ceased.  Meadows*  published  a  very  interesting  case  of 
inguinal  hernia  of  the  right  ovary,  which  was  successfully  removed. 
In  other  cases  extirpation  is  not  necessary,  the  hernia  being  found 
reducible  after  incision  of  the  ring.  Loper^  obtained  a  cure  in  this 
way.  The  case  was  one  of  inguinal  hernia  of  the  right  ovary  occur- 
ring after  delivery  in  the  sac  of  an  old  enterocele.  Kelotomy  neces- 
sitated the  destruction  of  some  adhesions  and  also  incision  in  order 
to  allow  of  the  reduction  of  the  ovary.  The  operation  was  followed 
by  cure.  By  adding  these  three  cases  to  those  already  recorded  we 
find  that  out  of  sixteen  cases  of  reduction  or  extirpation  of  ruptured 
ovaries  there  have  been  nine  definite  cures  and  seven  deaths,  five  of 
which  followed  extirpation.     Although  these   statistics  are  not  en- 

'  Balin,  Art  de  guerir  les  hernies,  p.  150.  Paris,  1768. — Widerstein,  Gazette 
hebdomadaire  de  medecine,  1853,  p.  79. — B^ekiovzik,  Monatssch.  fiii'  Geburtsk., 
Bd.  xvi,  S.  475,  1860. 

^  Owen,  British  Med.  Journal,  13  Dec,  1873. — Wibaich,  Theses  de  Paris, 
1874,  no.  469. 

^  Pott's  Works,  vol.  iii,  p.  329.  London,  1783. — MacClmr,  American  Journal 
of  Obstetrics,  vol.  vi,  p.  613. 

■•  Trans,  of  the  Obstet.  Soc.  London,  1861,  p.  438. 

*  Monatssch.  fiir  Oeburtsh.,  1866,  S.  453. 


DISPLACEMENTS  351 

couraging  we  cannot  avoid  the  necessity  of  operation  when  life  is  in 
danger,  but  it  should  only  be  resorted  to  in  such  cases. 

We  may  therefore  lay  down  the  following  rules :  1,  to  incise  and 
reduce,  in  children  and  young  women,  congenital  and  recent  herniaj 
which  have  neither  been  inflamed  nor  as  yet  present  any  extensive 
adhesions ;  2,  to  protect,  in  women  who  are  mothers,  by  means  of  a 
truss  with  a  concave  pad,  hernise  which  are  not  very  painful,  but  which 
have  become  irreducible  owing  to  adhesions;  3,  only  extirpate  the 
ovaries  when  the  hernia  is  irreducible,  adherent,  painful,  and  has  de- 
veloped symptoms  of  strangulation  and  inflammation  which  have 
resisted  antiphlogistic  treatment  and  endanger  life. 

2.  Hernia  of  til e  Uterus  {EysteroceleY 

It  is  not  uncommon  to  see  the  uterus,  when  distended  by  preg- 
nancy, protrude  between  the  recti  muscles  (separated  by  several  pre- 
ceding pregnancies),  and  hang  down  like  a  kind  of  wallet,  even  as  low 
as  the  thighs  when  the  excessively  distended  linea  alba  is  incapable  of 
supporting  it ;  it  is  rare,  however,  to  see  this  organ  undergo  the 
displacement  for  which  the  name  of  hernia  is  reserved.  A  certain 
number  of  authentic  facts,  however,  prove  that  the  uterus  may  be 
dragged  a  certain  distance  from  its  normal  position  and,  with  other 
abdominal  viscera,  become  surrounded  by  a  hernial  sac,  in  which  it 
may  become  developed,  contain  the  product  of  conception,  and  reach 
the  natural  term  of  gestation. 

I.  Hernise  of  the  uterus  during  pregnancy  ought  not  to  be  confounded,^ 
as  they  have  been  by  Desormeaux  and  Dubois,^  with  those  pro- 
jections of  the  gravid  womb  which  take  place  owing  to  a  stretching 
of  the  linea  alba  or  of  some  other  part  of  the  musculo-aponeurotic 
walls  of  the  abdomen.  There  is  a  great  difference  between  this 
accident  commonly  known  as  pendulous  belly,  and  real  uterine  hernia, 
whether  produced  by  an  artificial  opening  caused  by  stretching  or 
effected  through  the  natural  openings  or  through  the  abdominal  rings 
which  usually  give  passage  to  other  ruptured  viscera. 

Hernia  of  the  linea  alba  may  occur  during  gestation  and  even  at 
the  moment  of  delivery.^  Inguinal  hernia  may  also  take  place  during 
gestation,  in  spite  of  the  great  development  of  the  uterus  in  advanced 
pregnancy,  its  production  being  favoured  by  the  anterior  existence  of 
a  large  enterocele.  The  circumstances  which  favour  and  those  which 
determine  the  formation  of  these  herniae  are  very  variable,  as  the  fol- 
lowing facts  seem  to  show. 

Sennert  ^  relates  that  a  cooper's  wife  received  a  blow  from  a  stick 
in  the  groin  at  the  beginning  of  pregnancy ;  a  few  days  later  a  hernia 

'  Doering,  Tie  liernicB  uterina  atque  hancjusto  tempore  sifhsequentis  partus 
Ccesarei  historid.  Vitemb.,  1612. — One  ides,  Dissert,  de  hernia  uteri.  Leyde, 
1780. 

-  liepertoire  general  des  sciences  medicales,  t.  xxx,  p.  331.  Paris,  1846. 

^  J.  L.  Petit,  quoted  by  Boivin  and  Duges. — Paccini,  Hernia  of  tlie  linea 
alba  ;  operation,  cure.  Gazette  medicale  de  Paris,  1834,  p.  409.— John  Bell,  two 
cases,  Id.,  ibid.,  1849,  p.  308. 

■*  Medic,  practica,  lib.  iv,  sect.  2,  chap,  xvii,  p.  654,  quoted  by  Verdier, 
Memoires  de  V Academic  royale  de  chirurgie,  t.  ii,  p.  2. 


352  UTERINE    DISEASES    IN   DETAIL 

was  seen  at  this  point;  it  was  formed  by  the  uterus.  The  pregnancy- 
reached  term  ;  the  Caesarian  operation  w'as  performed ;  the  chUd  lived 
nine  years,  the  woman  died  suddenly  on  the  twentieth  day,  the 
autopsy  failing  to  reveal  the  cause  of  death. 

DcEring  ^  in  a  letter  to  Fabrice  of  Hilden,  gives  the  history  of  a 
woman  who  at  her  last  pregnancy  had  a  hernia  of  the  uterus,  probably 
inguinal,  and  who  had  also  to  undergo  the  Csesarian  operation  ;  the  child 
although  robust  died  in  a  few  months,  the  mother  succumbed  in  three 
days ;  Cruveilhier  thinks  that  the  hernia  existed  before  pregnancy  and 
that  it  was  wrong  to  perform  the  Csesarian  section ;  the  following  fact 
seems  to  justify  this  opinion.  Saxtorph  "  relates  that  a  woman  had  a 
tumour  in  the  inguinal  region  for  some  years ;  she  became  pregnant 
for  the  fifth  time;  during  pregnancy  the  tumour  gradually  increased, 
the  uterus  evidently  being  contained  in  it ;  delivery  took  place  natur- 
ally and  the  uterus  remained  projecting  under  the  integument.  In 
other  cases,  however,  the  hernia  has  really  been  produced  during  ges- 
tation, and  when  it  has  been  impossible  for  delivery  to  be  effected 
naturally,  Csesarian  section  has  occasionally  been  successful.  Eousset^ 
tells  of  a  woman  whose  uterus  had  escaped  through  the  centre  of  the 
abdomen  and  who  yet  had  a  natural  delivery ;  after  another  pregnancy 
the  result  was  equally  favorable,  although  the  hernia  was  irreducible. 
Euysch  ^  relates  the  case  of  a  uterine  hernia  produced  after  an  abscess, 
which  was  reduced  at  the  time  of  delivery  by  the  midwife  and  parturi- 
tion was  normal.  Ledesma  ^  has  seen  a  right  inguinal  hernia  of  the 
uterus  produced  in  the  third  month  of  a  seventh  pregnancy,  in  a 
woman  previously  affected,  and  even  before  marriage,  with  inguinal 
enterocele.  Attempts  at  reduction  having  failed  he  performed  the 
Csesarian  operation,  which  was  successful  as  regards  both  mother  and 
child;  the  uterus  continued  irreducible.  Fischer  ^  met  with  a  woman 
of  forty-four  who  had  had  seven  children,  and  who  suffered  greatly  at 
every  pregnancy  from  a  large  right  inguinal  hernia,  which  she  had  ten 
years  before  her  marriage.  Towards  the  end  of  her  eighth  pregnancy 
the  uterus  escaped  through  the  inguinal  ring  and  was  held  fixed  by 
the  neck  of  the  sac;  labour  having  commenced  with  rupture  of  the 
bag  of  waters  without  being  able  to  terminate  naturally,  Csesarian 
section  was  performed.    The  patient  died  the  fifth  day,  the  child  lived. 

II.  Hernise  of  the  unimj^regnated  uterus  are  more  difficult  to  explain 
on  account  of  the  deep  position  of  this  organ ;  they  probably  often 
depend  on  a  congenital  tendency  or  on  the  appendages  of  one  side, 
which  have  been  previously  displaced,  dragging  on  the  uterus.  They 
have  been  found  m  several  autopsies.'     Cruveilhier  thinks  that  hernia 

1  CEuvres  de  Fahrice  de  Eilden,  p.  833,  edit,  of  1646. 

"  Bibliotheque  medic,  t.  Ixvii,  p.  59. 

•''  Boyer,  Traite  des  mal.  chirurg.,  t.  ix,  p.  386. 

"'  Advers.  anat.  medic,  deca.,  ii,  p.  23. 

*  Journal  de  la  Soc.  de  vied.  prat,  de  Montpellier,  t.  i,  p.  441.  Montpellier, 
1840. 

^  Annales  de  la  chirurgie  frangaise  et  etrangere,  t.  v,  p.  249.  Paris,  1842. 

^  Chopart  et  Desault,  Traite  des  vial,  chirurg.  et  des  oper.  qui  lew  con- 
viennent,t.u, -p.  SOo.—lLaWement,  Mem.  de  la  Soc.  vied,  d'emul..,  3*  annee, 


DISPLACEMENTS  353 

of  the  uterus  is  usually  consecutive  to  that  of  the  ovary  and  Pallopian 
tube,  and  that  the  womb  is  gradually  displaced  by  a  kind  of  attraction. 
Deneux  explains  how  uterine  hernia  follows  that  of  the  ovary  by 
means  of  a  double  movement  of  rotation  from  below  upwards  and 
from  one  side  to  the  other ;  the  fundus  looks  forwards,  the  posterior 
surface  becomes  lateral,  the  angle  corresponding  to  the  affected  ap- 
pendages is  naturally  drawn  towards  the  ring,  and  finally  passes 
through  it ;  the  enlarged  size  of  the  hernial  sac  is  made  partly  at 
the  expense  of  the  broad  ligament  which  is  also  displaced.  Hernia  of 
the  ovary  would  in  this  case  be  the  first  stage  of  a  displacement,  of 
which  the  last  stage  would  be  hernia  of  the  uterus  ;^  hence  the  utility 
of  describing  these  displacements  together.  However,  in  the  Atlas  of 
Boivin  and  Duges  (PI.  xi,  fig.  3)  there  is  a  drawing  after  Cloquet,  of 
a  right  crural  hernia  of  the  uterus,  ovaries  and  Fallopian  tubes,  in 
a  newly-born  child,  where  the  fundus  of  the  uterus  seems  to  have 
been  first  displaced.  The  persistence  of  the  canal  of  Nuck  after 
birth  explains  the  possibility  of  hernia  of  the  uterus ;  the  position  of 
the  uterus  and  its  annexes  above  the  pelvic  cavity  at  birth  accounts 
for  its  comparative  frequency  in  children.  To  sum  up,  there  are 
several  varieties  of  uterine  as  of  intestinal  hernia,  according  to  the 
position  and  anatomical  relations  of  the  sac  :  1  Inguinal  liyderocele. 
Sometimes  the  whole  uterus,  sometimes  the  fundus  only,  enters  the 
external  inguinal  ring  or  only  the  internal.  These  cases,  quoted  by 
Chopart,  Lallement  and  Cruveilhier  are  very  rare,  especially  those  in 
which  the  displacement  affected  the  gravid  uterus.  Several  of  the 
cases  published  are  doubtful,  or  may  be  considered  as  extra-uterine 
pregnancies  occurring  beyond  the  inguinal  canal ;  Skrivan  and 
Lumpe^s^  cases  may  be  interpreted  in  this  way.  A  real  hernia  of  a 
gravid  uterus  can  only  take  place  through  the  inguinal  canal  when  it 
has  been  preceded  by  a  very  large  intestinal  hernia. — 2.  Crural 
hjsterocele.  The  fundus  enters  the  crural  ring.  Sennert,  Doering, 
Saxtorph^  have  seen  it  occur  in  pregnancy,  and  Lallement  in  the  uu- 
impregnated  state. — 3.  Umbilical  hysterocele  has  never  been  seen 
hitherto  except  in  the  gravid  uterus.  The  cases  mentioned  by 
Leotaud*  and  Murray^  may  be  added  to  those  already  cited  :  in 
Murray^s  case  reduction  was  effected  ;  in  Leotaud's  reduction  was 
very  easy,  but  the  tumour  could  not  be  kept  reduced  without  em- 
barrassing the  respiration  excessively.  Delivery  took  place  at  term 
without  any  accident. — 4.  Ventral  hysierocele  is  the  most  frequent ; 
it  is  sometimes  produced  after  rupture  of  the  aponeuroses,  especially 
at  the  linea  alba,  sometimes  after  laceration  of  the  abdominal  muscles, 
especially  of  the  recti.     I  have  seen  three  cases — two  on  the  linea 

p.  323,  and  Bulletin  de  la  Faculte  de  med.  de  Paris,  t.  i,  p.  1. — Cruveilhier, 
Anat.  pttthol.,  xxxiv**  liv.,  pi.  6. 

'  Beitrdye  zur  Gehurtsh.  und  GynaeTc.,  Bd.  vii,  1870. 

2  Zeitschrift  der  Ges.  der  Aertze.  Vienna,  1851,  No.  9,  and  1853,  No.  6. 

3  Colled.  Soc.  Hafn.,  1775,  t.  ii,  p.  323. 
"•  Gazette  des  Iwjpitaux,  1859,  p.  419. 

^  Lancet,  April,  1859. — Journal   des   connaissances  medico-cliirurgicales,^ 
1859,  p.  654. 

23 


354  UTERINE   DISEASES    IN    DETAIL 

alba  and  one  on  the  right  side  of  the  hypogastrium.  Puech  had 
a  case  of  this  kind  as  the  result  of  several  deliveries  in  quick  suc- 
cession. 

The  diagnosis  of  uterine  hernia  is  not  difficult,  even  in  the  unim- 
pregnated  organ;  palpation  associated  with  vaginal  touch  will  help 
the  practitioner  to  distinguish  the  nature  of  the  tumour  and  the 
kind  of  displacement.  It  is  not  indispensable  to  feel  the  point 
of  a  sound  introduced  into  the  uterine  cavity  through  the  sac,  as 
Kiwisch^  says. 

Treatment  is  less  easy.  In  the  rare  cases  in  which  the  hernia  is 
reducible,  reduction  should  be  made  and  maintained  by  a  bandage,  as 
in  the  treatment  of  enterocele.  In  the  more  frequent  cases  in  which 
the  existence  of  adhesions  or  the  development  of  pregnancy  renders 
reduction  impossible,  we  must  content  ourselves  with  supporting  the 
uterus  by  means  of  a  well-made  and  very  elastic  abdominal  belt,  or 
by  means  of  a  truss,  to  which  if  necessary  an  elevated  point  d'appui 
can  be  given  by  making  it  pass  over  the  shoulders.  When  pregnancy 
exists  and  the  hernia  takes  place  through  a  natural  opening  like  the 
inguinal  ring,  which  is  not  susceptible  of  much  dilatation,  instead  of 
through  the  stretched  linea  alba,  which  one  may  hope  still  further  to 
enlarge,  several  suggestions  occur  :  Should  attempts  at  reduction  be 
made  involving  incision  of  the  ring  as  in  cases  of  strangulated  hernia  ? 
Should  abortion  be  induced  in  order  to  prevent  the  dangers  which 
delivery  at  term  would  cause  to  the  mother  ?  To  these  questions  I 
can  give  no  positive  answer.  Lastly,  when  the  ruptured  uterus. has 
reached  the  term  of  gestation  there  is  no  room  for  hesitation. 
Cfesarian  section  must  be  performed  at  the  very  commencement  of 
labour;  experience  having  shown  that  it  has  sometimes  saved  the 
mother  as  well  as  the  child. 

3.  Horizontal  Displacements 

Horizontal  displacements  {antero-,  retro-,  or  latero-positions)  can 
hardly  be  produced  except  by  the  development  of  a  tumour  in  some 
part  of  the  uterus  (sub-peritoneal  fibro-myoma)  or  in  the  pelvic  cavity, 
either  a  retro-uterine  hematocele,  a  phlegmon,  pelvi-peritonitis,  a 
multilocular  cyst  or  some  other  malady  of  the  ovary,  disease  of  the 
bladder  or  rectum,  or  a  tumour  of  the  bones  of  the  pelvis,  &c.  It  is 
seldom  that  they  are  not  complicated  with  deviation.  The  diagnosis  is 
easy.  As  for  treatment,  since  they  do  not  constitute  a  disease  but 
only  a  symptom,  we  must  discover  the  malady  which  has  caused  them 
and  treat  it. 

The  uterus  may  be  "^w^h-Q^  forwards  against  the  pubis  by  a  fibroma^ 

^  Scanzoni,  op.  cit.,  p.  121. 

^  I  have  lately  seen  a  patient  die  from  the  effects  of  the  compression  exer- 
cised by  a  fibro-myoma  of  the  posterior  segment  of  the  uterus  upon  the  neck 
of  the  bladder  and  the  rectum,  the  functions  of  which  had  been  totally  sus- 
pended by  the  development  of  the  tumour  within  the  pelvic  cavity  and  the 
consequent  flattening  of  the  large  intestine,  which  had  become  quite  im- 
permeable to  the  faeces.      Unfortunately  the    patient,  to    whom  I    proposed 


DISPLACEMENTS  355 

or  a  retro-uterine  or  a  retro- vaginal  cyst,  by  a  hematocele,  by  inflam- 
mation, retro-uterine  pelvi-peritonitis,  an  abscess  in  the  same  region, 
a  rectal  tumour,  or  sometimes  even  a  stercoraceous  one,  so  as  to  pre- 
vent micturition,  and  may  only  be  perceptible  to  the  finger  at  the  bottom 
of  a  narrow  groove.  Less  frequently  it  is  pushed  bachvards,  usually  by 
a  fibro-myoma  of  the  anterior  wall,  or  an  anterior  sub- peritoneal 
tumour.  Lastly,  it  may  be  pushed  to  one  side  by  a  tumour,  a  cyst  of 
the  ovary  or  broad  ligament,  or  an  inflammatory  swelling  of  the  same 
ligament.  To  sum  up,  this  displacement,  though  of  little  consequence 
as  regards  the  uterus  itself,  becomes  a  valuable  sign  of  the  development 
of  one  or  other  of  the  diseases  just  referred  to. 

Slight  lateral  displacements  may  sometimes  be  observed,  depending 
on  a  congenital  tendency,  like  those  of  which  Cruveilhier^  speaks,  and 
which  Freund^  has  shown  by  his  researches  must  be  attributed  to  the 
central,  left  lateral,  or  exceptionally  to  the  right  lateral  position  of  the 
rectum,  differences  of  situation  which  may  cause  lateral  displacements 
of  the  uterus  in  an  opposite  direction. 

I  have  also  seen  the  uterus  occupy  a  position  anterior  or  posterior 
to  its  normal  position  in  the  pelvis,  and  which  did  not  seem  to  depend 
on  any  peri-uterine  malady,  but  on  a  congenital  anomaly,  especially  on 
a  relative  shortness  of  one  of  the  vaginal  walls  (for  I  have  observed 
that  this  shortness  coincided  almost  always  with  one  or  other  of  these 
antero-posterior  displacements) . 

4.  Ascent  of  the  Uterus 

The  ascent  of  the  uterus,  which  is  more  frequently  met  with  in 
pregnancy  than  in  a  state  of  vacuity,  may,  according  to  Colombat,^  be 
determined  by  a  number  of  causes,  among  others  by  a  defect  in  the 
length  and  width  of  the  uterine  ligaments,  by  inflammation,  engorge- 
ment and  dropsy  of  the  Fallopian  tubes  and  ovaries,  extra-uterine 
pregnancy,  the  first  stage  of  ante  version  and  retroversion,  and  lastly, 
by  the  dilatation  of  the  uterine  cavity  by  hydatids  and  other  foreign 
bodies. 

Sometimes,  as  Goupil  observes,*  there  is  in  very  rare  cases  con- 
genital elevation  of  the  uterus,  depending  probably  on  the  shortness  of 
the  utero-lumbar  ligaments,  the  abnormal  length  of  the  vagina,  the 
height  of  the  patient,  or  sometimes  even  on  her  embonpoint.  In  most 
cases,  however,  ascent  of  the  uterus,  like  its  horizontal  displacements, 
is  symptomatic  of  a  disease  in  this  organ  or  outside  it.  It  may  be 
caused  by  a  hematocele,  pelvic  tumour,  or  some  disease  outside  the 
organ.  Contrary,  however,  to  horizontal  displacements,  it  is  generally 
caused  by  the  development  of  the  uterus  itself,  or  at  least  of  its  appen- 

hystei'otomy,  refused  to  be  operated  on.  The  neck  was  firrnlj  pressed  against 
the  pubis. 

'  Anat.  descript.,  Splanclmologie,  p.  471.  Paris,  1865. 

^  Die  Lageentwichelung  der  Beckenorgane,  &c.  Breslau,  1864. 

*  Traits  complet  des  maladies  des  femmes,  t.  i,  p.  339.  Paris,  1843. 

■*  Bernutz  et  Goupil,  CUnique  medicale  sur  les  maladies  des  femmes,  t.  ii, 
p.  614.  Paris,  1862. 


356  UTEEINE   DISEASES    IN    DETAIL 

dages.  This  ascent  is  sometimes  the  symptom  of  a  purely  physio- 
logical state,  such  as  pregnancy.  At  other  times  it  depends  on  the 
increased  size  of  the  uterus,  due  to  various  pathological  conditions, 
such  as  a  polypus,  hypertrophy,  a  mole,  and  especially  a  fibrous  body. 
In  all  these  cases  it  is  owing  to  its  increased  size  that  the  uterus  can 
no  longer  be  contained  in  the  pelvic  cavity,  and  gradually  rises  above 
the  brim.  A  large  ovarian  cyst,  especially  if  there  are  adhesions 
between  the  ovary  and  the  uterus,  may  drag  the  uterus  up  with  it. 
Peritoneal  adhesions  occurring  after  delivery  between  the  fundus  of  the 
uterus  and  the  abdominal  or  pelvic  walls  may  produce  the  same  effect. 
Ascent  of  the  uterus  is  often  accompanied  by  elongation  or  dragging 
of  the  vagina,  the  effacement  of  its  folds  and  disappearance  of  its  cul- 
de-sac,  with  elongation,  atrophic  wasting,  and  finally,  laceration  of  the 
cervix} 

Ascent  of  the  uterus  as  a  symptom  should  also  attract  the  attention 
of  the  physician,  leading  him  to  search  for  the  cause  of  the  displace- 
ment. It  is  evident  that  ascent  of  the  womb  causes,  in  its  turn,  dis- 
tension and  elongation  of  the  vagina,  sometimes  disappearance  of  the 
vaginal  portion  of  the  cervix,  increased  size  of  the  uterine  cavities,  or 
other  symptoms  varying  with  the  cause  which  has  determined  the 
ascent. 

Treatment  can  only  be  applied  to  the  cause  on  which  the  displace- 
ment depends. 

5.  Descent  of  the  Uterus 

There  are  three  degrees  of  prolapsus  or  descent  of  the  uterus,  the 
last  of  which  goes  by  the  name  of  procidentia.  The  first  degree  of 
prolapsus  may  extend  to  contact  of  the  vaginal  portion  of  the  neck 
with  the  perineeal  floor.  The  second  degree  is  characterised  by  the  pre- 
sence of  the  cervix  at  the  vulva.  The  third  degree  qx  procidentia  sup- 
poses the  uterus  outside  the  vagina  and  vulva  hanging  down  between 
the  thighs.^  This  malady  evidently  offers  great  varieties  as  to  degree, 
form  and  complications,  several  of  which  have  lately  been  brought  to 
light.  Amongst  the  works  which  have  contributed  most  to  show  the 
way  in  which  uterine  prolapsus  is  produced,  and  to  distinguish  it  from 
the  diseases  which  may  simulate  or  complicate  it,  we  may  mention 
those  of  Boivin  and  Duges,^  on  the  part  which  relaxation  of  the  utero- 
sacral  ligaments  play,  Huguier's*  paper  on  the  hypertrophic  elonga- 
tion of  the  cervix,  and  Legendre's^  experiments  on  the  phenomena 
which  take  place  when  traction  is  made  on  the  uterus  of  a  dead  body 
so  as  to  drag  it  downwards. 

'  Nunn,  Pathol.  Transact.,  vol.  x. — Barnes,  op.  cit.,  p.  678. 

^  Gosselin,  CUniq.  chirurg.,  t.  ii,  p.  534.  Paris,  1873. — Barnes  considers 
prolapsus  as  invagination  of  the  uterus  by  the  vagina ;  procidentia  as  com- 
plete inversion  of  the  vagina  or  uterine  hernia  through  the  vagina. 

3  Op.  cit.,  i,  84. 

*  Op.  cit.  Paris,  1859.  ^ 

^  De  la  chute  de  Vuterus.  Competition  thesis,  p.  104.  Paris,  1860.  See 
also  Savage's  work,  The  Female  Pelvic  Organs,  Tab.  xi,  and  Transact,  of  the 
Obstet.  Sac.  of  London,  vol.  x,  p.  235. 


DISPLACEMENTS  357 

The  observation  of  pathological  facts  shows  that  prolapsus  may 
either  afifect  the  wliole  uterus  or  the  cervix  only^  owing  to  the  hyper- 
trophic elongation  of  this  segment  of  the  uterus ;  prolapsus  of  the 
cervix  (which  is  then  the  symptom  of  a  disease  quite  different  from 
real  prolapsus  of  the  womb)  is  incomplete  when  the  hypertrophy  only 
affects  the  vaginal  portion,  complete  when  both  parts  are  affected.^ 
On  the  other  hand,  prolapsus  may  be  simple  or  complex :  simple  when 
the  cervix  occupies  the  summit  of  the  vaginal  invagination,  when  the 
uterus  is  in  a  normal  state,  and  unaccompanied  by  any  other  organ  in 
its  displacement ;  complex  when  the  neighbouring  organs  are  diseased 
or  displaced,  or  when  the  uterus  itself  presents  an  important  physiolo- 
gical or  pathological  alteration.  The  chief  complications  depending 
on  the  neighbouring  organs  are  :  cystocele,  stone  in  the  bladder,  recto- 
cele,  hsemorrlioidal  tumours,  even  intestinal  hernise  in  more  or  less 
distant  parts.  The  chief  complications  on  the  side  of  the  uterus  are : 
pregnancy,  hypertrophy  and  elongation,  engorgement,  congestion, 
softening,  inflammation,  excoriations,  ulcers,  leucorrhcea,  polypi,  devia- 
tions, flexions  and  inversion. 

Such  are  the  elements  which  ought  to  serve  as  a  basis  for  the 
various  indications  when  it  is  a  question  of  treatment.  It  is  an 
important  element  in  the  success  of  this  treatment,  and  in  the  diag- 
nosis of  the  malady,  to  determine  the  anatomo -pathological  alterations 
which  prolapsus  produces  in  the  uterus  and  in  the  neighbouring 
parts. 

In  prolapsus  the  uterus  is  still  contained  in  the  pelvis,  and  the 
disease  may  be  difficult  to  distinguish  from  simple  hypertrophic  elon- 
gation of  the  cervix  or  body ;  all  the  more  so  as  there  may  be  longi- 
tudinal hypertrophy  of  this  organ  without  prolapsus. 

In  procidentia,  the  uterus  being  outside  the  pelvis,  a  vacuum  is 
necessarily  produced  in  the  region  which  it  occupied,  and  consequently 
a  cul-de-sac  presents  itself  above  the  displaced  uterus  containing  the 
Fallopian  tubes,  ovaries  and  one  or  more  knuckles  of  intestine;  before 
and  behind  this  organ  are  prolongations  of  the  vesico-uterine  and 
recto-uterine  peritoneal  culs-de-sac  ;  the  fundus  of  the  bladder  adher- 
ing to  the  cervix  of  the  uterus  is  necessarily  involved  in  its  descent 
and  forms,  in  the  anterior  part  of  the  tumour,  in  front  of  the  womb, 
below  the  urethral  canal,  a  diverticulum  or  cavity  accessory  to  the 
vesical  cavity^  which  thus  in  many  cases  becomes  bilobed,  owing  to 
the  uterine  fundus  being  on  a  level  with  the  inferior  outlet  of  the 
pelvis;  the  rectum  may  accompany  the  displacement  of  the  womb 
behind,  as  the  bladder  does  in  front. 

The  surface  of  the  tumour  is  nothing  but  the  vaginal  mucous  mem- 
brane inverted  by  a  kind  of  displacement  similar  to  that  which  the 
intestinal  mucous  membrane  sometimes  undergoes,  especially  in  the 
rectum,  and  which  is  designated  invagination  ;  this  invagination  offers 
degrees  corresponding  to  those  of  the  descent  of  the  womb  :  it  may 
begin  at  the  upper  part,  and  this  usually  happens  when  the  uterine 

'  See  Ascent  of  the  Utertis,  p.  355.  Tins  elongation  may  even  occur  without 
hypertrophy  :  see  Sims,  op.  cit.,  p.  353. 


358 


UTERINE    DISEASES    IX    DETAIL 


displacement  is  primarily  owing  to  defective  resistance  of  the  suspen- 
sory ligaments ;  it  may,  however,  also  commence  at  the  lower  portion 
of  the  vagina,  in  which  case  it  is  produced  independently  of  the  uterine 


Fig.  252. — Procidentia  vrith  cystocele,  two  peritoneal  cuh-de-sac,  an  anterior 
and  posterior,  half  natural  size ;  preparation  in  St.  George's  Mnseum 
(after  Barnes).  This  preparation  is  similar  to  that  represented  in  Cniveil- 
hier's  Anatomie  pathologique,  26«  liAa-aison,  pi.  4,  fig.  2.  m,  womb  ; 
o,  ovary  ;  E,  rectum ;  a,  anus  ;  p,  pubis  ;  T,  bladder  ;  V,  urethra  ;  G, 
cystocele  ;  T,  vesical  trigone  at  the  base  of  the  bladder  fonning  the  cysto- 
cele ;  P  A,  anterior  peritoneal  cul-de-sac  ;  p  p,  posterior  peritoneal  cul-de-sac. 

prolapsus  or  concurrently  with  it,  by  the  relaxation  of  the  vaginal 
mucous  membrane,  the  loosening  of  its  adhesions  to  the  neighbouring 
parts,  and  by  defective  resistance  of  the  perinseal  floor,  &c. 

"When  procidentia  is  complete  invagination  of  the  vaginal  mucous 
membrane  is  so  also,  and  this  membrane  becomes  external,  convex, 
distended  by  the  organs,  which  are  pushed  down  with  it,  and  to  which 
it  forms  a  common  envelope.  The  phenomena  which  occur  in  the 
accomplishment  of  this  morbid  act  are  therefore  in  some  respects 
similar  to  those  produced  in  cases  of  invagination  or  prolapse  of  the 
rectum. 

Prolapsus  of  the  vagina  may  take  place  without  displacement  of  the 
uterus  and  other  pelvic  organs.  It  may  be  dependent,  as  West  rightly 
remarks,  on  a  kind  of  hypertrophy  of  this  canal,  which   prevents  it 


DISPLACEMENTS 


359 


from  remaining  within  its  own  limits,  pushing  one  of  its  folds  out  of 
the  vulva.  This  hypertrophy  occurs  usually  during  pregnancy.  The 
vagina,  like  the  uterus,  increases  in  length  (which  allows  the  uterus  to 
rise  above  the  pelvis)  and  in  breadth  (which  allows  the  head  of  the 
foetus  to  escape),  without  speaking  of  its  thickness.  After  delivery,  if 
the  retrograde  evolution  of  the  vagina  is  arrested  in  its  progress,  as 
sometimes  happens  with  the  uterus,  and  especially  if  the  perinseum  has 
been  injured,  whenever  the  patient  attempts  to  walk  or  make  any  other 
exertion,  the  vagina  will  descend  and  project  beyond  the  vulva. 


^^    -     ^^^.         / 


Fig.  253. — Cystocele  of  the  first  degree  of  procidentia,  complicated  by  haemor- 
rhoids (Sims). 

Cystocele  and  rectocele,  like  vaginal  invagination,  not  only  often 
comphcate  prolapsus,  but  frequently  precede  it.  The  tumour  acquires 
thereby  greater  size ;  the  defective  resistance  of  the  perinseal  floor, 
indicated  by  the  premature  appearance  of  these  complications,  is  a 
condition  unfavorable  for  treatment.  The  presence  of  peritoneal  ciils 
de-sac  before  and  behind  the  uterus  is  still  more  so,  and  ought  to  be 
seriously  taken  into  consideration  in  cases  where  excision  of  a  part 
of  the  tumour  or  cauterisation  of  the  vagina  would  seem  to  be 
indicated. 

The  cervix  uteri,  normal  or  altered  by  disease,  is  to  be  found  in  the 
centre  of  the  tumour;  sometimes  contracted,  at  other  times  affected 
with  a  kind  of  eversion  or  ectropion,  which  exposes  a  portion  of  the 
cervical  ca\aty  externally,  as  if  the  invagination  which  had  begun  upon 


360  UTERINE    DISEASES  IN    DETAIL 

the  vaginal  mucous  membrane  was  gradually  continued  on  the  uterine 
walls,  effecting  eversion.  In  any  case  this  ectropion  is  the  end  and 
not  the  commencement  of  prolapsus.^ 

Usually  the  uterus  becomes  congested  and  hypertrophied,  owing  to 
its  descent.  This  hypertrophy  may  either  affect  the  whole  organ  or  a 
portion  of  it  only,  most  frequently  the  cervix,  either  in  its  infra- 
vaginal  or  supra-vaginal  part.  In  this  case  the  hypertrophy  is  the 
consequence  of  the  prolapsus,  whilst  at  other  times  it  is  the  cause 
of  it. 

The  suspensory  ligaments  are,  perhaps,  of  all  the  organs  of  the 
uterine  system  those  which  undergo  the  most  serious  alterations. 
These  utero-sacral  and  utero-lumbar  ligaments,  covered  by  the  folds 
of  Douglas,  are  sometimes  torn,  more  frequently  completely  relaxed, 
the  only  vestiges  of  them  remaining  being  a  few  folds  stretched  out  in 
the  form  of  a  fan  in  the  sacro-iliac  cavity,  which  go  into  folds  when 
the  uterus  is  brought  back  into  its  normal  position.  The  broad  liga- 
ments may  become  puckered,  held  back  by  bands  of  adhesion,  suffering 
from  the  effects  of  displacement  without  having  contributed  to  produce 
it.  The  round  ligaments  have  still  less  share  in  displacement,  neither 
undergoing  any  modification  nor  losing  their  ordinary  flexuosity.  The 
vulva  is  very  much  distended,  the  posterior  commissure  effaced,  the 
perinseum  very  much  thinned,  and  its  rupture  is  the  final  act  in  pro- 
ducing prolapsus.^  The  descent  of  the  uterus,  therefore,  does  not 
depend  on  this  organ  itself,  but  on  alterations  in  the  organs  which 
support  it  and  maintain  it  in  its  position. 

We  may  say  of  this,  as  of  all  displacements,  that  it  is  less  a  disease 
than  a  symptom — a  symptom  of  disease  or  traumatism  of  the  suspen- 
sory ligaments,  a  symptom  of  a  pathological  condition  of  the  neigh- 
bouring organs,  of  the  perinseum,  vulval  opening,  &c.  Therefore  it 
usually  only  occurs  in  flabby  women  after  numerous  deliveries,  or  after 
laceration  of  the  perinseum  or  accidental  rupture  of  the  utero-lumbar 
ligaments  from  a  fall  or  violent  effort.  It  is  not  uncommon  to  find  in 
patients  affected  with  hernia  displacements  of  the  same  kind,  attribu- 
table to  the  same  troublesome  tendency  of  the  organism.  I  know  a 
lady  who  suffers  simultaneously  from  two  inguinal  hernise,  an  umbilical 
hernia  and  a  prolapsus  uteri.  Prolapsus,  however,  may  occur  in 
young  girls,^  either  from  a  congenital  tendency,  an  original  laxity  of 
the  ligaments,  or  from  the  effects  of  a  sudden  rupture  of  the  utero- 
lumbar  ligaments  or  the  perinseum  by  a  fall  or  a  violent  effort.  De 
Graaf,  Saviard,  Mauriceau,  Chopart  and  other  writers  have  related 
cases  of  the  kind. 

Among  the  predisposing  causes  of  prolapsus  may  be  placed  those 
general  diseases  which  make  their  influence  felt  on  the  pelvic  organs. 
Tuberculous  women  are  subject  to  it.     Beigel  (op.  cit.,  t.  ii,  p.  291) 

^  Scanzoni,  op.  cit.,  p.  128. — Jobert,  Union  med.,  1858. — Le  Grendre,  op.  cit., 
p.  64. — Boivin  and  Duges,  Atlas,  pi.  ix,  fig.  8. 

^  Matthews  Duncan,  On  the  Function  of  the  Perinceum  in  Procidentia 
Uteri— Edin.  Med.  Journal,  1871,  p.  673. 

'  Churchill,  Diseases  of  Women,  p.  431.  Dublin,  1864. — Monro,  Edin.  Med. 
Essays,  iii,  282. — Nonat,  op.  cit.,  p.  444. 


DISPLACEMENTS  361 

found  sixty-four  cases  of  it  out  of  140  tuberculous  women,  among 
others  a  lady,  who  having  lost  20  lbs.  in  weight  in  a  very  short  time 
by  practising  Banting,  found  herself  one  day  without  any  cause  a 
sufferer  from  prolapsus.  It  occurs  also  in  women  whose  occupations 
oblige  them  to  stand,  make  violent  efforts,  &c.,  e.g.  washerwomen, 
workwomen  and  charwomen,  singers,  and,  according  to  Klinge,^  nuns 
suffer  more  frequently  than  others  from  prolapsus  from  prolonged 
standing  and  kneeling  and  from  singing.  A  wide  pelvis  with  ampli- 
tude and  relaxation  of  the  vagina  dispose  to  prolapsus  uteri,  as  also  do 
tumours  and  increased  weight  of  the  uterus.  These  pliysiological  or 
pathological  conditions,  however,  are  not  sufficient-  to  produce  it. 
There  must  be  rupture  or  relaxation  of  the  suspensory  ligaments.  The 
resistance  of  these  ligaments  is  what  really  prevents  prolapsus,  the 
resistance  of  the  perinseum  and  the  neighbouring  parts  is  only  a 
secondary  obstacle  to  the  final  accomplishment  of  its  descent.  Eelaxa- 
tion  of  the  utero-sacral  ligaments  being  also  the  indispensable  condition 
of  retroversion,  as  we  shall  afterwards  see,  it  follows  that  retroversion 
usually  precedes  prolapsus  and  is,  so  to  say,  the  first  stage  of  it.  This 
has  been  remarked  by  several  practitioners.  West  says  that  every 
prolapsed  uterus  is  also  more  or  less  retroverted.  According  to  Sims,^ 
there  must  be  retroversion  before  procidentia  can  take  place,  retrover- 
sion involving  relaxation  of  all  the  ligaments ;  the  existence  of  ante- 
version  makes  prolapsus  impossible.  According  to  Barnes  also,  the 
uterus  cannot  descend  when  auteverted.  As  soon  as  there  is  retrover- 
sion the  relaxation  of  the  suspensory  ligaments  and  the  weight  of  the 
intestines  upon  the  anterior  surface  of  the  uterus  tend  to  lower  it  and 
to  increase  the  displacement.  This  fact  cannot  be  too  much  insisted 
on.  As  another  consequence,  owing  to  the  impossibility  of  restoring 
the  resistance  of  the  lumbar  ligaments,  it  follows  that  it  is  impossible 
to  effect  a  radical  cure  in  a  woman  affected  with  procidentia,  and  from 
the  possibility  of  restoring  vaginal,  vulval  and  perinseal  resistance,  or  of 
supplying  it  artificially,  the  possibility  of  a  palliative  cure  may  be 
deduced. 

We  cannot  hope  to  reach  the  causes  which  have  produced  the  dis- 
placement ;  they  have  either  ceased  long  ago,  or  their  persistent 
nature  defies  almost  all  our  means  of  action.  They  divide  themselves 
into  two  classes,  according  to  whether  the  disease  has  been  produced 
suddenly  or  slowly.  In  the  first  case  a  fall,  a  violent  effort,  the  act 
of  raising  a  heavy  weight,  &c.,  has  ruptured  the  utero-sacral  ligaments, 
either  from  excess  of  the  tension  which  the  heavy  uterus  has  exercised 
on  them,  or  from  the  energy  of  the  muscular  contraction  displayed, 
and  has  pushed  the  uterus  outside  the  external  organs  of  generation, 
as  it  may  push  the  intestine  outside  the  rings  and  produce  a  hernia. 
In  the  second  case,  the  continued  weight  of  the  womb,  the  repetition 
of  efforts  produced  by  constipation  or  by  any  other  action  necessitating 
the   bent  position,   continuous  pressure  exercised   on  the   abdominal 

1  Dissertatio  de  procidenti  uteri  ususque  pessariorwin  in  hoc  morho.  Got- 
tingen,  1867. 

2  Op.  cit.,  p.  295. 


362  TJTEEINB   DISEASES   IN  DETAIL 

organs  and  tending  to  make  the  uterus  descend  (any  action  apparently 
slight,  the  slow  and  continuous  persistence  of  which,  however,  greatly 
increases  its  importance),  gradually  relax  the  lumbar  ligaments,  deprive 
them  of  all  elasticity,  increase  their  length,  and  act  in  the  same  way 
on  the  perinseal  resistance,  producing  irremediable  displacement  of  the 
organ.  The  first  mode  is  the  cause  of  prolapsus  in  young  women ; 
the  second  is  more  frequently  met  with  in  old  women. 

The  importance  of  the  part  which  pregnancy  plays  may  lead  us  to 
presume  that  the  age  when  prolapsus  occurs  is  most  frequently  that 
of  sexual  activity.  Verdier^  out  of  156  cases  counted  7  as  occurring 
between  the  ages  of  sixteen  and  twenty,  21  between  twenty-one  and 
twenty-five,  38  between  twenty-six  and  thirty,  33  between  thirty-one 
and  thirty-five,  25  between  thirty-six  and  forty,  16  between  forty-one 
and  forty-five,  9  between  forty-six  and  fifty,  9  between  fifty-one  and 
sixty-three.  BeigeP  met  with  1  in  a  woman  of  ninety-two,  which 
was  produced  at  thirty ;  Monro^  observed  1  in  a  child  of  three  ;  and 
Wiilaume'*  1  in  a  newly-born  infant. 

The  experiments  of  Le  Gendre^  and  Bastien  allow  of  our  measuring 
approximately  the  amount  of  force  necessary  to  produce  procidentia 
and  to  destroy  the  resistance  of  the  uterine  ligaments.  A  force  of 
from  45  lbs.  to  50  lbs.  is  sufficient  to  force  the  cervix  to  the  vulva. 
Experience  proves  that  this  result  may  be  obtained  by  distension  of 
the  suspensory  ligaments,  without  causing  any  permanent  elongation 
and  still  less  a  rupture  of  these  organs,  as  we  see  that  the  uterus 
when  left  to  itself  resumes  its  normal  position  and  preserves  it  inde- 
finitely after  operations  for  vaginal  fistula,  excision  of  polypi  and  abla- 
tion of  fibrous  bodies,  all  of  which  necessitate  drawing  down  of  the 
uterus.  By  applying  a  force  of  111  lbs.  to  traction  exercised  on  the 
uterus,  this  organ  is  drawn  through  the  vulva  and  prolapsus  is  pro- 
duced. By  slow  traction  the  same  result  is  obtained  with  less  force. 
In  this  way  moderate  but  continuous  pressure  produces  the  same 
result.  Tumours,  which  sometimes  raise  the  uterus  out  of  the  pelvis, 
pull  it  down,  on  the  contrary,  when  the  circumstances  are  reversed. 
Beigel  observed  a  case  of  prolapsus  caused  by  an  increase  in  the  size  of 
the  liver,  another  by  the  spleen.  Dilatation  of  the  bladder  or  rectum, 
or  a  stercoraceous  tumour  may  do  the  same. — Tumours  of  the  vulva 
may  influence  the  vagina,  causing  invagination  and  subsequent 
prolapsus. 

The  relative  frequency  of  prolapsus,  which  greatly  exceeds  that  of 
all  other  displacements,  is  easily  explained,  for  so  many  circumstances 
conspire  to  drag  the  uterus  down  :  this  organ  is  suspended  in  a 
large  cavity  by  means  of  ligaments  susceptible  of  extension;  its 
weight  and  size  may  considerably  increase  under  the  influence  of  con- 

^  Traits  pratique  cles  hernies,  deplacements  et  maladies  de  la  onatrice. 
Paris,  1840. 

2  Op.  cit.,  t.  ii,  p.  291. 

^  Edin.  Medic.  Essay,  vol.  iii,  p.  282. 

■*  Beigel,  op.  cit.,  t.  ii,  p.  291. 

5  Op.  cit.,  p.  104. 


DISPLACEMENTS  363 

ditions  which  also  diminish  the  resistance  of  the  ligaments;  one  of 
these  conditions  occurs  very  frequently,  viz.  pregnancy ;  lastly,  it  is 
naturally  pushed  downwards  by  the  weight  of  the  viscera  and  by  the 
contractions  of  the  abdominal  muscles.  With  such  predispositions  a 
relatively  insignificant  cause  suffices  to  produce  prolapsus. 

Diagnosis — suhjective  signs. — When  prolapsus  is  not  produced 
suddenly,  patients  experience  symptoms  which  attract  their  attention 
before  the  appearance  of  a  tumour  at  the  vulva :  discomfort,  weight, 
dragging  in  the  loins,  abdominal  pains  radiating  sometimes  into  the 
groins,  downward  pressure  on  the  perinseum,  weight  in  the  pelvic 
cavity,  as  if  the  contents  were  drawn  outwards,  occasionally  vaginal 
tenesmus,  frequent  desire  to  micturate  and  go  to  stool,  vesical  and 
rectal  tenesmus,  pain  at  the  points  where  the  pelvic  nerves  are  com- 
pressed, painful  pressure  of  the  uterus  on  the  hymen  in  virgins,  in- 
crease of  all  these  symptoms  at  the  menstrual  period,  nervous  erethism, 
digestive  troubles :  such  are  the  phenomena  which  strike  the  attention 
at  first.  When  the  tumour  appears  at  the  vulva  the  preceding  sym- 
ptoms persist,  but  are  diminished  when  the  patients  are  at  rest,  and 
especially  when  lying,  and  increased  when  they  stand  long,  when  they 
have  to  make  violent  eff'orts  or  lift  weights.  Patients  experience  a 
sensation  which  makes  them  fear  that  the  womb  or  other  organs  con- 
tained in  the  pelvis  are  on  the  point  of  falling ;  it  seems  as  if  a  part 
of  themselves  is  drawn  downwards.  Cazalis  and  Le  Gendre  have  drawn 
attention  to  a  phenomenon  that  is  very  persistent,  that  is,  vaginal 
tenesmus  or  that  inclination  to  strain,  to  expel  the  tumour,  which  is 
caused  by  chronic  congestion  and  by  the  vague  dull  pains  felt  in  the 
bottom  of  the  cavity,  and  which  is  also  occasioned  by  hsemorrhoidal 
tumours;  this  tenesmus  is  probably  not  without  influence  on  the 
descent  of  the  vaginal  mucous  membrane.  The  tumour  itself  is  not 
generally  painful,  and  when  it  has  lasted  for  some  time  the  action  of 
the  air  often  renders  it  insensible ;  for  the  membrane  covering  it  has 
exchanged  the  characteristics  of  a  mucous  membrane  for  those  of  skin, 
its  epithelium  has  become  an  epidermis,  which  tolerates  the  contact  of 
neighbouring  parts. 

Two  general  remarks  may  be  made  about  these  various  symptoms. 
The  first  is  that  they  are  more  marked  when  the  prolapsus  is  not  con- 
secutive to  a  delivery  or  miscarriage,  and  especially  when  it  has  occurred 
suddenly.  The  second  is  that  they  are  not  always  in  proportion  to 
the  gravity  of  the  displacement,  but  rather  to  the  complications  of  the 
prolapsus  and  the  nervous  sensibility  of  the  patient.  In  some  women 
menstruation  may  be  arrested  or  be  irregular,  whilst  in  others  it  may 
be  increased,  though  this  seldom  happens ;  the  tumour  which  is  re- 
ducible in  the  intercalary  period  may  become  irreducible  and  undergo 
strangulation  at  the  menstrual  period,  as  in  a  case  seen  by  Linas.^ 
The  congestion  which  is  kept  up  in  the  uterus  by  its  descent  does  not 
only  determine  pain  in  the  organ,  it  also  increases  its  weight  and  size, 
causing  hypertrophy  which  tends  to  perpetuate  the  displacement ; 
sometimes  it  even  produces  passive  haemorrhage  and  uterine  leucor- 
'  Xonat,  op.  cit.,  \).  448. 


364  UTERINE    DISEASES    IN    DETAIL 

rhoea,  without  counting  possible  disorders  of  the  appendages.^  Unless 
the  tumour  is  irreducible,  marital  intercourse  is  quite  possible,  for  the 
dorsal  decubitus  enables  the  patient  to  replace  the  uterus ;  there  are 
cases  in  which  intromission  has  taken  place  into  the  uterine  orifice.^ 
Therefore  it  is  not  rare  to  see  women  suffering  from  prolapsus  become 
pregnant.  In  such  cases  the  prolapsus  should  be  reduced  as  soon  as 
possible ;  sometimes  reduction  takes  place  spontaneously,  and  owing  to 
the  ascent  of  the  uterus  above  the  pelvic  cavity  after  the  third  month, 
the  patients  are  temporarily  delivered  from  this  infirmity.^  It  is  not 
indeed  impossible  for  gestation  to  take  place  in  complete  procidentia, 
the  patient  being  obliged  to  support  the  uterus  between  her  thighs 
during  pregnancy,  till  the  time  comes  when  the  contractions  of  this 
organ  are  sufficient  to  accomplish  delivery.  Examples  of  this  are  given 
by  Wagner,  Chopart,  Nonat,^  &c. 

In  a  few  cases  pregnancy  follows  its  normal  course.  When  the 
uterus  has  not  remained  entirely  outside  the  pelvis,  prolapsus  of  the 
cervix  and  part  of  the  body  is  likely  to  be  reproduced  at  the  moment 
of  delivery  and  obliges  the  accoucheur  to  resort  to  version.^ 

A  peculiar  sensation  of  dragging  at  the  umbilicus,  vesical  tenesmus 
and  difficulty  in  micturition  depend  on  repletion  of  the  prolapsed 
bladder  with  the  anterior  vaginal  wall,  on  the  formation  of  the  diver- 
ticulum of  this  organ  as  it  is  dragged  into  the  cystocele,  and  on  the 
deviation  of  the  urethral  canal,  which  in  place  of  being  directed 
towards  the  pubis,  is  directed  downwards  towards  the  bottom  of  the 
bladder,  being  dragged  by  the  uterus ;  it  follows  that  patients  in  order 
to  empty  the  bladder  have  to  strain  in  the  bent  position,  which  is  so 
favorable  to  prolapsus,  making  violent  efforts  alike  prejudicial  to  their 
condition  and  useless  in  securing  micturition ;  and  are  often  obliged  to 
bend  forwards  and  to  compress  the  cystocele,  in  order  to  raise  the 
vesical  diverticulum  and  empty  the  bladder. ^  The  urine  which,  for 
reasons  just  indicated,  cannot  be  expelled  to  any  distance,  runs  over 
the  tumour,  irritating  and  ulcerating  the  vaginal  mucous  membrane 
so  much  as  sometimes  to  produce  gangrene  and  cause  vesico-vaginal 
fistula.''  Sometimes  there  is  retention  necessitating  the  use  of  the 
catheter  which  is  often  attended  with  difficulty,  and  this  is  followed  by 

'  Otto  von  Franque,  Der  Vorfall  der  Gebdrmutter  in  anatomischer  und 
Jclinischer  Beziehung.  Wiirzburg,  1860,  S.  13. 

^  Hervey  and  Franque,  op.  cit.,  p.  14. 

^  Kiwisch,  Klinische  Vortrdge,  Bd.  i,  S.  159.  Prague,  1854. 

■*  Op.  cit.,  p.  451. 

*  See  d'Erchia,  II  filiatre  sebezio,  1867. — Amussat,  Gazette  med.  de  Paris, 
1832,  p.  588.— Husty,  Monatssch.,  Bd.  xx,  S.  248.— Gussecow,  Id.,  Bd.  xxi,  S.  99. 
— Needon,  Id.,  Bd.  xxiii,  S.  222'. — Aubinais,  Gaz.  des  hopitaux,  1866,  p.  378. — 
Frage,  Gaz.  med.  de  Paris,  2  Dec,  1866. — Sattler,  Zeitschrift  filr  Wunddrzte 
und  Geburtshillfe,  1872,  No.  3. — Rubicki,  Virchow's  Jahresbericht,  1873,  S. 
660. — Burns,  Principles  of  Midwifery.  London,  1824,  p.  130. 

^  This  mechanical  irritation  of  the  urethra,  according  to  several  surgeons, 
accounts  for  the  presence,  in  these  patients  more  frequently  than  in  others,  of 
fungous  excrescences  of  the  urethra,  and  small  polypi  in  the  meatus,  which 
form  an  obstacle  to  micturition  and  add  to  the  discomfort  of  the  patient. 

^  Scanzoni,  op.  cit.,  p.  129. 


DISPLACEMENTS 


365 


incontinence  of  urine.  One  consequence  of  this  accident  is  the  decom- 
position of  the  urine^  which  becomes  thick  and  viscous,  and  charged 
with  phosphates.  Another  troublesome  consequence  is  degeneration 
of  the  kidneys ;  the  ureters,  being  stretched  and  compressed/  become 
dilated  as  well  as  the  pelvis  of  the  kidney,  and  in  course  of  time  the 
secreting  substance  of  the  kidneys  atrophies  (Kiwisch  and  Yirchow) . 
Another  consequence  of  the  retention  of  the  urine  in  this  diverticulum 
is  the  formation  of  vesical  calculi,  or  their  increase  in  cases  where  they 
existed  before  the  cystocele  (Ruysch,  Ferra,  Cruveilhier,  Gosselin, 
Goupil,  &c.).  Lastly,  the  vesical  mucous  membrane  may  itself 
become  the  seat  of  a  muco-purulent  secretion  and  of  a  concretion  of 
urinary  deposits  which  produce,  especially  in  its  vaginal  diverticulum, 
an  accumulation  of  a  more  or  less  considerable  number  of  vesical 
calculi."  Eoper  ^  has  met  with  several  together  which  could  be  moved 
under  the  fingers. 


Pig.  254. — Incomplete    procidentia    uteri,  witli    liypertropliy   of   the  vaginal 
poi-tion  of  the  cervix  (after  Sims). 

With  regard  to  the  rectum,  we  find  pains,  tenesmus,  difficult  defe- 
cation, obstinate  constipation,  inflammation  and  ulceration  of  the 
mucous  membrane  owing  to  the  contact  with  fsecal  matter,*  and  in  the 
case  of  rectocele,  an  accumulation  in  the  intestinal  diverticulum  of 

'  Philippe  {British  Med.  Journal,  p.  128,  1870)  describes  two  cases  in  which 
the  ureters,  compressed  directly  by  the  tumour,  dilated  and  gave  rise  to  uraemia, 
followed  by  fatal  results. 

2  Blandin,  quoted  by  Le  Gendre,  op.  cit.,  p.  76. 

^  Barnes,  op.  cit.,  p.  632. 

*  Huguier,  Allomjements  Injpertrojyhiques  du  col. 


366 


UTEEINE    DISEASES    IN    DETAIL 


fseces  which  the  patients  are  obh'ged  to  force  back  with  the  tumour  in 
order  that  they  may  escape  by  the  anus. 

Objective  symptoms. — Direct  examination  by  touch  and  sight  suffice 
to  make  diagnosis  easy.  The  first  symptom  is  the  presence  of  a 
tumour  at  or  outside  the  vulva.  This  tumour,  which  is  pear  shaped, 
directed  downwards  and  surrounded  by  folds  of  vaginal  mucous  mem- 
brane, keeps  the  labia  apart ;  the  surface  is  red  or  pink,  dry,  smooth, 
sometimes  excoriated ;  the  top,  conical  or  slightly  swollen,  presents  a 
transverse  fissure,  the  os  uteri,  from  which  there  is  an  exudation  of 
mucus ;  the  base  seems  sometimes  pediculated  by  constriction  of  the 
vulval  ring ;  in  front  of  it  may  be  seen  the  meatus  ;  and  behind  it  the 
perinseum  forced  back,  projecting  and  diminished  in  its  antero-pos- 
terior  diameter ;  the  anus  itself  may  project,  giving  passage  to  a 
hernia  of  its  mucous  membrane. 

This  soft  depressible  tumour,  mobile  in  every  direction,  and  easily 
pushed  back,  gives  a  sensation  of  great  resistance.  It  can  be  reduced 
completely,  and  is  reproduced  with  great  facility.  In  this  double 
movement  the  reduction  and  invagination  of  the  mucous  membrane 
can  be  easily  ascertained.  When  inversion  of  the  vagina  is  not  com- 
plete, a  circular  groove  may  be  felt  more  or  less  marked  above  the 
tumour;  this  is  the  portion  of  the  vaginal  mucous  membrane  which 
has  not  been  inverted,  under  which  the  characteristic  hardness  of  the 
uterus  may  be  perceived.  Rectal  touch  allows  the  diagnosis  to  be 
completed  by  determining  the  position  occupied  by  the  uterine  fundus 


Fia.  255. — Complete  procidentia  uteri  of  twenty  years'  standing,  in  a  woman 

of  seventy  years. 


DISPLACEMENTS 


367 


below  the  pelvic  cavity  ;  whilst  catheterism  discloses  the  cystocele,  and 
by  associating  it  with  rectal  touch  the  information  given  by  the  latter 
as  to  the  descent  of  the  fundus  ideri  and  its  absence  from  the  cavity 
is  confirmed.  The  form  of  the  tumour^  resembling  at  first  that  of  the 
neck,  afterwards  becomes  conical,  surrounded  by  folds  at  its  base, 
and  finally  gets  more  and  more  globular  and  smooth  in  proportion  as 
its  size  increases.  Its  volume  may  become  very  considerable,  when 
in  addition  to  prolapsus  of  the  uterus  there  is  also  prolapsus  of  the 
vagina,  bladder,  rectum  and  small  intestine,  the  latter  known  by  its 
gurgling  and  filling  the  posterior  peritoneal  cul-de-sac  ;  an  extreme 
case  which  is  very  rare,  but  which  is  possible,  for  I  have  seen  a  case 
of  the  kind :  it  may  reach  the  size  of  the  head  of  a  foetus  and  even 
of  an  adult.  Defecation  and  micturition  are  considerably  impeded, 
especially  if  the  tumour  is  irreducible. 

The  colour  of  the  vaginal  mucous  membrane  with  which  the 
tumour  is  covered  is  also  gradually  altered  by  the  congestion  which 
makes  it  darker  by  exposure  to  the  air,  and  by  friction  which  imparts 
to  it  a  greyish  tint,  and  by  irritation  and  inflammation  which  produce 


Fig.  256. — Complete  •procidentia  uteri  with  cystocele  and  rectocele,  hyper- 
trophy and  ulceration  of  the  cervix  and  eversion  of  the  cervical  mucous 
membrane  (after  Sims). 

ulceration  in  the  neighbourhood  of  the  urethra  and  the  most  depend- 
ent portion  of  the  tumour.  Continued  contact  with  the  external  air 
renders  this  membrane  dry  and  discoloured,  imparting  to  it  the  charac- 
teristics of  skin^  without,  however,  preventing  it  from  regaining  its  pro- 

^  This  is  so  true,  that  in  an  old  negress  affected  for  fifty  years  with  complete 
procidentia  this  membrane  became  as  black  as  the  skin,  and  was  even  covered 
with  down. 


368  UTEEINE   DISEASES   IN    DETAIL 

perties  of  mucous  membrane  should  the  tumour  be  retained  for  a  time 
in  the  pelvic  cavity ;  but  if  the  tumour  increases  in  size  and  remains  ex- 
ternalj  its  mucous  membrane  and  the  adjacent  tissues  become  congested, 
thickened,  hypertrophied,  whilst  those  parts  exposed  to  friction  pre- 
sent irregular  ulcers  in  patches,  from  which  a  little  pus  is  excreted 
and  which  sometimes  beconie  affected  Mdth  gangrene.  The  uterine 
orifice,  as  well  as  the  isthmus  and  cavity  of  the  body,  which  are  ob- 
literated in  aged  women,  are,  on  the  contrary,  sometimes  dilated  in 
young  women ;  I  have  already  spoken  of  this  peculiar  dilatation  and 
eversion  which  may  extend  to  five  centimetres  in  diameter,^  and  conse- 
quently be  sufficient  to  admit  the  penis,  examples  of  which  eminent 
writers  have  given  us.  Palpation  and  percussion  of  the  tumour  may 
give  the  sensation  of  fluctuation  in  front.  Pressure  on  the  same  point 
makes  the  urine  escape  from  the  meatus.  Compression  of  the  whole 
of  the  tumoui-,  which  is  not  painful  in  chronic  prolapsus,  diminishes 
the  volume  and  communicates  a  sensation  of  internal  resistance  pro- 
duced by  a  cylindrical  organ  larger  above  than  below,  terminating  on 
a  level  with  the  upper  and  strangulated  part  of  the  tumour,  and 
possessing  all  the  characteristics  of  the  uterus.  It  is  not  always  easy 
to  reach  above  the  body ;  but  the  neck  is  more  easily  perceived  through 
the  inverted  vagina,  because  of  its  being  harder,  longer,  more  cylin- 
drical than  in  a  normal  condition,  especially  in  the  numerous  cases  in 
which  the  displacement  of  the  cervix  depends  on  the  elongation  of  the 
neck  more  than  on  the  descent  of  the  uterus.  The  presence  of  the 
intestines  in  the  posterior  peritoneal  cul-de-sac  is  recognised  by  the 
peculiar  gurgling  sound  heard  when  reduction  is  being  made. 
Catheterisation  shows  the  direction  of  the  urethra  towards  the  lowest 
part  of  the  tumour,  the  existence  and  extent  of  the  diverticulum  of 
the  bladder,  and  consequently  the  lowest  limits  of  the  cystocele,  and 
lastly,  the  upper  limit  of  the  uterus  in  the  centre  of  the  tumour.  By 
rectal  touch  we  discover  the  rectocele,  the  position,  deviations  or 
curves  of  the  uterus,  and  the  elongation  of  the  suspensory  ligaments. 
Lastly,  the  use  of  the  uterine  sound  allows  us  to  determine  in  a  still 
more  precise  manner  the  upper  border  of  the  uterus,  the  length  of  its 
vertical  diameter,  and  consequently  the  absence  or  development  of  the 
longitudinal  hypertrophy  of  the  neck,  and  lastly,  the  various  altera- 
tions in  the  direction  of  this  organ.  I  do  not  understand  the  danger 
that  Le  Gendre  apprehends  from  its  use.^ 

Differential  diagnosis. — The  characteristics  just  enumerated  hardly 
allow  of  our  failing  to  recognise  an  infirmity  so  marked  as  uterine  pro- 
lapsus ;  it  is  not,  however,  so  easy  to  distinguish  simple  from  compli- 
cated cases,  nor  to  determine  the  nature  of  the  complications. 
Tumours  arising  from  the  cervix  or  even  from  the  cavity  of  the  body 
often  project  at  the  vulva,  or  outside,  gradually  dragging  the  uterus  with 
them  especially  when  they  are  large,  and  causing  vaginal  invagination 
to  some  extent,  which  is  another  cause  of  error.  These  fibrous, 
mucous,  follicular  polypi  are  difficult  to  distinguish  from  prolapsus  by 

1  Huguier,  Allong.  hypertropliiqiie. 
»  Op.  cit.,  p.  68. 


DISPLACEMENTS 


369 


their  external  aspect,  on  account  of  the  alterations  affecting  the 
vaginal  mucous  membrane  when  the  prolapsus  is  of  long  standing. 
It  might  be  thought  that  the  existence  of  the  os  uteri  allowing  the 
sound  to  penetrate  into  the  uterine  cavity  would  be  a  sufficiently  dis- 
tinctive mark ;  it  is  not  so,  however,  for  the  orifice  may  be  obliterated 
or  hidden,  e.g.  pushed  forward  by  uterine  retroversion  (co-incident 
with  prolapsus),  which  places  the  fundus  of  the  uterus  in  the  posterior 
peritoneal  cul-de-sac,  and  its  cervix  in  front  against  the  pubis.  In 
such  cases  catheterisation  and  rectal  touch  will  help  to  show  the 
absence  of  the  uterus  from  the  cavity,  and  to  determine  the  ex- 
istence of  retroversion  in  the  tumour.  As  for  vulval  or  extra-vulval 
tumours,  in  the  formation  of  which  the  uterus  does  not  participate, 
such  as  cystocele,  rectocele,  cysts  of  the  labia  and  vagina,  catheterisa- 
tion, rectal  and  vaginal  touch  suffice  to  determine  which  organ  is  dis- 
placed and  whether  the  uterus  occupies  its  normal  position.  There 
is,  however,  one  malady  which  it  is  especially  important  to  distinguish 
from  prolapsus  nteri,  viz.  uterine  inversion.  It  must  be  remembered 
that  uterine  inversion  does  not  necessarily  involve  propulsion  of  a 
tumour  outside  the  vaginal  cavity,  and  that  when  this  is  produced  it  is 
because  prolapsus  is  added  to  inversion  owing  to  the  elongation  or 
rupture  of  the  utero-sacral   ligaments.      Now,  inversion  is   almost 


-Complete  procidentia  uteri 


Fig.  258. — Complete  inversion  of  the 
uterus  complicated  by  vaginal  in- 
vagination or  uterine  prolapsus. 


always  produced  suddenly,  from  traction  exercised  on  the  adherent 
placenta,  or  from  violent  eS'orts  accompanying  the  expulsion  of  the 
foetus,  from  a  fibrous  tumour  or  a  polypus.  The  surface  of  the 
tumour  has  the  spotted  aspect  of  the  congested  uterine  mucous  mem- 
brane in  place  of  the  wrinkles  of  the  vaginal  mucous  membrane ;  it 
often  causes  dangerous  haemorrhages  ;  it  is  globular,  broader  below 
than  at  the  vulva,  where  there  is  a  strangulated  pedicle ;  on  a  level 
with  this  pedicle  the  vaginal  culs-de-sac  and  uterine  lips  may  be  seen, 

24 


370  UTEEINE    DISEASES    IN    DETAIL 

the  outline  of  which  may  be  followed  by  the  finger,  whether  the  inver- 
sion has  affected  them  and  the  neighbouring  part  of  the  vagina,  or 
whether  they  have  kept  their  normal  position,  surrounding  the  portion 
of  the  inverted  neck  with  a  kind  of  ring.  This  tumour  shows  no 
trace  of  an  os  uteri.  Lastly,  neither  rectal  nor  vaginal  touch,  nor  yet 
catheterisation,  discloses  the  presence  of  the  body  of  the  uterus, 
supposing  it  has  remained  large  enough  and  soft  enough  to  be  pene- 
trable. Pregnancy  is  said  to  be  a  complication  not  unfrequently 
met  with,  especially  when  prolapsus  is  incomplete  and  the  largest  part 
of  the  organ  is  still  contained  in  the  cavity.  The  presumptive  signs 
of  pregnancy,  especially  the  rapid  development  of  the  uterine  tumour 
in  a  woman  whose  youth  and  health  exclude  the  idea  of  any  disease, 
and  later  on  the  signs  of  certainty,  can  leave  no  doubt  as  to  the 
existence  of  this  complication.  It  is  evident  that  prolapsus  even  in 
the  first  degree  is  an  obstacle  to  the  regular  progress  of  gestation. 
If  the  uterus  cannot  be  reduced  grave  symptoms  may  arise,  followed 
frequently  by  abortion  or  miscarriage.  The  dead  foetus  has  been  seen 
to  remain  for  some  time  in  the  prolapsed  uterus  before  being  expelled ; 
in  a  few  cases,  to  which  I  have  already  referred,  pregnancy  has  termi- 
nated normally,  delivery  having  been  eflTected  solely  by  the  contrac- 
tion of  the  organ.  Catheterisation  reveals  the  existence  of  vesical 
calculi. 

Lastly,  the  hypertrophic  elongation  of  the  neck  is  beyond  doubt  the 
most  frequent  complication.  Huguier  regarded  the  majority  of  cases 
of  prolapsus  as  simple  inversion  of  the  vagina  gradually  pushed 
towards  the  vulva,  on  a  level  with,  or  outside  this  orifice,  by  the  pro- 
gressive elongation  of  the  hypertrophied  neck  of  the  uterus.  I  can, 
however,  afiirm  that  there  are  cases  of  simple  longitudinal  hypertrophy 
as  well  as  of  simple  prolapsus  and  even  procidentia  without  hyper- 
trophy, besides  a  great  number  of  cases  of  prolapsus  complicated  with 
more  or  less  marked  hypertrophy.  It  is  easy  to  see  that  constant 
congestion  of  the  prolapsed  uterus  at  last  causes  hypertrophy,  especially 
of  the  supra-vaginal  portion  of  the  cervix.  This  elongation  of  the 
neck  was  first  observed  by  Morgagni  •}  afterwards  described  by  Levret,^ 
was  called  by  Nivchow  prolapsus  of  the  uterus  without  procidentia  of 
theftmdus,^  and  was  exhaustively  studied  by  Huguier  under  the  name 
of  hypertrophic  elongations.*  We  may  add  that  prolapsus  must  also 
be  distinguished  from  hermaphroditism;  in  the  17th  century  a 
woman  was  taken  for  a  hermaphrodite  till  Saviard  ^  announced  that  he 
had  treated  her  for  prolapsus  uteri,  which  he  had  reduced.  Valentin 
saw  a  similar  case  :^  a  woman  was  taken  for  a  hermaphrodite  and 
accused  of  impotence ;  an  examination  showed  the  mistake,  the  uterus 
was  reduced  and  capacity  for  conjugal  intercourse  admitted. 

Treatment, — Uterine  prolapsus  hinders  women  from  moving  about 

1  Be  Sedibus,  Sec,  Epist.,  45,  art.  11. 

^  Journal  de  med.  et  de  chir.  de  Roux,  vol.  xl,  p.  352. 

^   Verhandlungen  der  Gesellschaft  fiir  GebiirtsJc.  Berlin,  Bd.  il,  S.j205. 

•*  Memoires  de  V Academie,  1859. 

*  Nouveau  reciieil  d' observations  chirurgicales. 

^  Franqiie,  op.  cit.,  p.  27. 


DISPLACEMENTS  371 

freely,  the  least  effort,  especially  that  of  lifting  weights,  bringing  on 
lumbar  and  pelvic  pain,  which  is  all  the  more  annoying  from  often 
being  incurable.  When  I  say  incurable,  I  mean  in  an  absolute 
manner;  for  there  is  no  reason  to  despair  of  ameliorating  the  evil,  or 
at  least  of  palliating  it.  It  is,  however,  alike  impossible  for  art  and 
nature  to  bring  about  a  complete  and  lasting  cure,  especially  when  the 
prolapsus  is  chronic  and  has  passed  into  the  state  of  complete  proci- 
dentia. Acute  prolapsus  is  more  easily  cured :  the  ligaments  which 
are  relaxed  are  elastic  like  the  tissue  of  the  organ  itself;  we  may 
therefore  hope  to  see  the  supports  of  the  womb  recover  a  certain 
degree  of  their  retractility,  sufficiently  so  to  retain  the  organ  in  a 
position  somewhat  similar  to  its  normal  one  if  we  lose  no  time  in 
applying  suitable  treatment. 

The  patient  should  observe  the  abdominal  rather  than  the  dorsal 
decubitus  in  order  to  help  the  uterus  to  ascend,  and  to  shorten  the 
distance  between  the  neck  and  the  promontory;  when  walking  the 
uterus  should  if  necessary  be  supported  by  a  Hodge  or  some  other 
kind  of  pessary,  the  bladder  should  be  kept  empty,  and  astringent 
applications  (powdered  tannin  in  a  small  pledget  of  cotton  wool) 
should  be  made  to  the  cervix.  On  the  other  hand,  prolapsus  when 
left  to  nature  has  a  tendency  to  increase  :  the  intestines  fill  the  vacuum 
left  by  the  uterus  in  the  pelvis,  preventing  this  organ  from  resuming 
its  own  place  and  continuing  to  push  it  down  by  the  pressure  which 
they  exercise  on  it,  whilst  the  prolapsus  of  the  vagina  is  daily  increased 
by  the  efforts  of  defecation.  The  presence  of  the  uterus  provokes 
expulsive  efforts  which  increase  the  evil.  I  know  that  the  possibility 
of  spontaneous  cure  has  been  admitted  by  some.  Scanzoni^  thinks 
that  peritonitis,  w^hich  is  sometimes  developed  after  traumatism  or 
delivery  in  a  woman  affected  with  prolapsus,  may,  by  determining 
adhesions  between  the  fundus  of  the  uterus  and  some  other  portion  of 
the  visceral  or  parietal  peritoneum,  become  the  means  of  retaining  the 
uterus  in  the  pelvic  cavity.  In  the  same  way  cicatricial  coarctations 
following  suppurative  vaginitis,  by  supporting  the  uterus  from  below 
and  preventing  its  falling  towards  the  vulva  so  as  to  invert  the  vagina, 
may  bring  about  natural  cures.  These  modes  of  cure,  however,  are 
very  rare  and  not  suitable  for  imitation  by  art.  We  must  therefore 
content  ourselves  with  a  palliative  cure  which  renders  the  infirmity 
supportable  and  prevents  the  displacement  from  being  produced  to  its 
full  extent,  without  hoping  to  modify  the  malady  itself,  the  relaxation, 
rupture  of  the  attachments,  &c.,  which  are  the  cause  of  the  displace- 
ment. The  measure  of  curability  is  furnished  by  the  relation  between 
the  indications  to  which  this  lesion  may  give  rise,  and  the  imperfect 
means  which  we  are  able  to  employ  in  order  to  fulfil  them. 

The  sources  of  therapeutic  indications  here  as  everywhere  lie  in  the 
pathological  elements  the  association  of  which  constitutes  prolapsus. 
The  treatment  necessarily  varies  with  the  case.  In  prolapsus  two 
distinct  pathological  states  must  be  admitted :  simple  prolapsus  of  a 
normal  uterus,  and  descent  of  the  vagina  from  a  hypertrophied  uterus. 

1  Op.  cit.,  p.  130. 


372  UTEEINE    DISEASES   IN    DETAIL 

Sometimes  weakening  of  the  suspensory  ligaments  is  the  primary 
cause  of  the  prolapsus;  sometimes  it  is  the  weight  of  the  womb 
increased  by  defective  involution,  congestion  or  hypertrophy.  These 
two  states  are  often  combined,  the  one  which  has  occurred  first  soon 
producing  the  other. 

1.  Let  us  first  take  simple  descent  of  the  uterus,  without  hyper- 
trophy. The  cause  of  the  displacement  is  not  in  the  womb  :  it  exists 
in  the  abdomen  above  or  below  the  uterus ;  above,  tumours,  dropsy, 
pressure,  efforts,  elongation  or  rupture  of  the  suspensory  ligaments, 
may  push  the  womb  downwards  or  let  it  fall;  below,  hypertrophy, 
tumours,  prolapsus  and  relaxation  of  the  vagina,  laceration  of  the 
perinseum,  may  draw  it  in  the  same  direction  or  withdraw  from  it  all 
support.  The  indications  are  two  :  one  easy,  reduction ;  one  difficult, 
retention.  Eeduction  may  take  place  simply,  if  there  is  no  other 
obstacle  than  vaginal  prolapsus,  by  taxis  similar  to  what  is  employed 
in  the  reduction  of  hernise.  It  may  necessitate  the  destruction  of 
obstacles  opposed  to  its  accomplishment,  e.g.  puncture  in  ascites  and 
in  ovarian  cysts,  the  application  of  belts  to  support  the  abdomen,  the 
ablation  of  vaginal  tumours,  &c.  In  order  to  maintain  reduction  the 
suspensory  ligaments  must  be  acted  on,  the  distended  ligaments 
shortened,  the  torn  ligaments  reunited,  contractility  restored  to  the 
paralysed  muscular  fibres,  the  last-named  being  only  possible  in  the 
beginning.  The  impossibility  of  acting  efiicaciously  by  these  means 
on  the  morbid  elements  to  which  they  are  addressed  has  led  to  the 
idea  of  maintaining  reduction  by  giving  tone  to  the  vagina  and  sup- 
porting the  perinseal  wall  by  bandages  or  pads ;  by  supplying  the  de- 
fective resistance  of  the  vulval  ring  and  vagina  by  intravaginal 
supports,  pessaries,  hysterophores ;  by  contracting  the  vaginal  or 
vulval  ring  by  excision,  either  circular,  longitudinal  or  in  folds 
(followed  by  adhesive  or  inodular  cicatrisation),  by  cauterisation,  by 
constriction  and  gangrene,  by  ligature,  suture,  or  by  any  other  means 
causing  loss  of  substance.  Lastly,  by  closing  the  vaginal  orifice  in- 
completely by  inSbulation,  or  completely  by  suture. 

2.  In  cases  of  prolapsi  uteri  with  elongation  the  hypertrophy  may 
afPect  either  the  body,  neck  or  isthmus,  and  be  produced  by  the 
development  of  tumours,  polypi,  fibromata,  or  by  various  alterations  of 
the  cervix,  by  a  hypertrophic  inflammation,  or  oftener  by  mere  hyper- 
trophy. There  are  two  indications :  one  or  other  may  be  fulfilled 
according  to  the  case.  The  cause  of  the  prolapsus  may  be  removed  by 
bringing  the  uterus  back  to  its  normal  dimensions,  i.  e.  by  favouring 
absorption  or  by  removing  tumours  developed  on  the  surface  or  in  the 
tissue  itself  by  excision,  crushing,  cauterisation,  ligature,  &c.,  or  the 
uterus  may  be  reduced  and  maintained  by  efficient  support  without 
removing  the  cause  of  the  descent.  This  palliative  cure  is  often  suffi- 
cient, the  compression  of  the  organ  being  tolerated  by  the  habit  which 
the  pelvis  has  contracted  of  containing  large  bodies,  especially  if  they 
are  flexible. 

3.  In  the  association  of  these  two  principal  varieties  of  prolapsus 
the  one  always  plays  the  part  of  complication  with  regard  to  the  other. 


DISPLACEMENTS  873 

It  is  important  to  distinguish  which  of  the  two  is  the  primary  malady 
and  which  the  secondary,  even  when  the  latter  has  acquired  a  major 
importance.  The  primitive  element  should  be  attacked  first,  and  then 
the  secondary,  which  has  become  permanent.  These  general  indications 
being  laid  down,  let  us  see  how  treatment  should  be  practically  carried 
out. 

I.  Reduction. — This  is  easy,  and  often  spontaneous.  In  most 
patients  the  horizontal  decubitus  on  the  abdomen  is  sufficient  to  cause 
the  entrance  of  the  tumour,  as  is  proved  by  the  facility  with  which 
conception  takes  place  in  such  cases.  In  a  few  patients  the  favorable 
tendency  of  the  horizontal  position  is  increased  by  the  natural  action 
of  the  vaginal  walls  (and  probably  also  of  the  ligaments),  which,  in 
contracting  from  below  upwards,  raise  the  uterus  so  as  to  replace  it  in 
the  pelvis.  Scanzoni  has  proved  this  by  projecting  cold  water  on  a 
prolapsus  the  size  of  the  fist,  which  then  entered  the  pelvis  sponta- 
neously. If  reduction  does  not  take  place  spontaneously  owing  to  the 
increase  of  volume  which  constriction  of  the  vulva  determines  in  the 
recent  or  congested  tumour,  or  if  it  is  desirable  to  use  some  means  of 
retention  in  cases  where  the  uterus  does  not  easily  rise,  artificial  reduc- 
tion must  be  made  by  performing  a  kmd  of  taxis  on  the  tumour  similar 
to  that  used  in  reducing  hernise.  1.  The  patient  lying  on  her  hack 
with  the  head  and  limbs  flexed  so  as  to  prevent  all  abdominal  pressure 
and  the  pelvis  slightly  raised,  the  tumour  is  grasped  with  both  hands 
and  compressed  in  such  a  manner  that  the  various  parts  composing  it 
rise  successively  irito  the  cavity.  The  uterus  may  either  be  first 
pushed  back,  the  reduction  of  the  vaginal  inversion  taking  place  after- 
wards, or  the  vaginal  wall  near  the  vulva,  as  well  as  the  rectocele  and 
cystocele  (when  these  complications  exist),  may  be  first  replaced  and 
the  womb  afterwards.  2.  If  difiiculty  is  experienced  in  effecting  re- 
duction when  the  patient  is  in  the  dorsal  decubitus,  we  take  advantage 
of  the  fact  that,  as  the  essential  causes  of  prolapsus  are  relaxation  of  the 
suspensory  ligaments  and  retroversion,  reduction  will  be  facihtated  by 
placing  the  uterus  in  anteversion,  and  by  bringing  the  neck  near  to  the 
sacro-lumbar  ligaments.  In  fact,  by  placing  the  patient  in  ventral 
pronation  on  elbows  and  knees  we  are  able  to  replace  the  uterus  much 
more  easily  than  in  any  other  way,  and  to  reduce  the  rectocele  and 
cystocele  at  the  same  time.  The  weight  of  the  abdominal  viscera 
descending  towards  the  umbiKcus,  the  traction  which  they  exercise  on 
the  womb,  and  the  entrance  of  air  into  the  vagina,  are  all  favorable 
conditions  for  facilitating  reduction. 

Whether  it  be  the  neck  or  vagina  which  has  escaped  first  in  the 
commencement  of  prolapsus,  there  is  no  doubt  it  is  the  vagina  which 
escapes  first  in  long-standing  procidentia.  If  after  having  replaced  the 
parts  in  their  normal  position  the  patient  is  asked  to  make  an  effort  to 
expel  them  anew,  the  anterior  vaginal  wall  will  be  seen  to  descend 
against  the  perinseum  in  the  form  of  a  cystocele.  A  slight  effort  will 
push  it  beyond  the  vulva,  and  the  neck  will  follow  immediately,  drag- 
ging with  it  the  posterior  wall  of  the  vagina.  In  reducing  procidentia 
we  must  therefore  reverse  this  order :  begin  by  replacing  the  posterior 


374  UTERINE   DISEASES   IN   DETAIL 

cul-de-sac,  then  the  neck;  the  anterior  wall  of  the  vagina  and  the 
bladder  will  follow  naturally.  The  swelling  which  has  occurred  in  the 
tumour  owing  to  congestion,  the  development  of  inflammatory  pheno- 
mena or  constriction  of  the  vulval  ring,  is  not  the  only  reason  why 
reduction  should  be  undertaken  at  once.  A  more  important  one  still 
is  pregnancy.  Although  in  this  latter  case  the  irreducible  uterus  may 
be  sufficiently  supported  by  a  suitable  bandage  to  reach  the  term  of 
gestation  without  accidents,  and  to  expel  a  living  fcetus  from  its  cavity, 
yet  it  is  prudent  to  attempt  reduction  before  the  size  of  the  foetus 
prevents  the  passage  of  the  womb  through  the  vulva  and  outlet. 
Mauriceau^  once  effected  reduction  at  the  fifth  month. 

The  prognosis  is  not  more  unfavorable  when  reduction  is  difficult. 
Provided  that  it  be  possible,  there  is  all  the  more  chance  that  it  will 
be  maintained  owing  to  the  resistance  of  the  vulva  and  perinseum.  If, 
however,  it  be  possible,  the  nature  of  the  obstacles  which  hinder  or 
retard  it  must  be  determined,  in  order  to  apply  an  appropriate  treat- 
ment. In  a  few  cases  reduction  is  impossible.  Tor  example,  a  number 
of  small  fibroid  tumours  filling  the  pelvic  cavity  may  prevent  it  (Sims). 
The  adhesions  of  intestinal  circumvolutions  to  the  internal  wall  of  the 
sac  may  be  another  cause.  If  there  is  merely  congestion  or  oedema, 
the  horizontal  position  of  the  patient,  elevation  of  the  tumour,  applica- 
tions of  cold,  astringents,  styptics  in  various  forms,  sufiice  to  facilitate 
reduction.  If  there  is  chronic  inflammation,  rest,  the  application  of 
leeches  to  the  cervix,  emollient  fomentations  and  the  use  of  other 
antiphlogistic  means,  are  usually  successful  in  diminishing  inflamma- 
tory tumefaction  sufficiently  to  allow  of  reduction  of  the  prolapsus. 
It  is  the  same  with  the  remarkable  and  frequent  hypertrophic  thicken- 
ing of  the  vaginal  walls :  rest,  the  horizontal  position,  applications  of 
glycerine,  resolvent  fomentations,  may  effect  modifications  favorable  to 
reduction.  Lastly,  the  parts  must  be  gradually  accustomed  to  resume 
a  position  which  has  become|abnormal  to  them. 

It  must  not  be  thought  that  ulcers  and  other  alterations  mentioned 
as  being  frequently  developed  on  the  vaginal  mucous  membrane  in 
long-standing  cases  of  prolapsus  are  contra-indications  to  reduction, 
and  necessitate  preliminary  treatment  as  Scanzoni  advises.  As  a  rule, 
the  mucous  membrane  is  cured  spontaneously  when  no  longer  exposed 
to  the  contact  of  air,  of  urine  and  to  friction.  Therefore  it  may  be  said 
that  reduction  is  usually  easy,  whatever  may  be  the  obstacles ;  all  that 
is  wanted  is  a  great  deal  of  patience.  Unfortunately,  however,  it  is 
difficult  to  maintain  the  tumour  reduced. 

II.  Retention. — Some  means  of  retention  are  only  used  as  pallia- 
tives, others  aim  at  producing  a  radical  cure.  The  former  are  all  the 
more  satisfactory  because,  without  pretending  to  efi'ect  a  radical  cure, 
they  sometimes  contribute  powerfully  to  it  by  enabling  the  ligaments 
to  recover  their  elasticity  and  the  uterine  supports  their  resistance ; 
whilst  every  day^s  experience  proves  that,  in  addition  to  the  danger 
which  accompanies  the  latter,  they  are  quite  insufficient  to  realise  the 

^  Observations  sur  la  grossesse  et  l' accouchement,  Obs.  95,  p.  78.  Paris, 
1728. 


DISPLACEMENTS  375 

aim  to  which  they  pretend.  Both,  but  especially  the  artificial  means 
of  retention,  may  be  helped  in  their  action  by  medical  treatment. 
Sometimes  this  is  the  only  treatment  that  can  be  used  and  we  should 
always  begin  with  it. 

A.  General  or  medical  treatment. — This  should  be  directed  against 
chronic  congestion,  engorgement  and  all  causes  of  increased  weight  of 
the  uterus,  as  well  as  against  debility,  laxity  of  the  ligaments,  defective 
tone  of  the  soft  parts  which  support  the  uterus,  and  of  the  whole 
organism.  Resolvents  associated  with  restoratives,  tonics,  hydropathy, 
&c.,  constitute  the  principal  agents  of  this  treatment. 

If  the  evil  is  due  to  a  labour  or  miscarriage,  to  fatigue  during  a 
menstrual  period  followed  by  neglect  at  the  following  periods,  then 
absolute  rest,  the  horizontal  position,  laxatives,  cold  sitz-baths,  astrin- 
gent injections,  vaginal  applications  of  tannin  or  alum,  local  depletion 
if  necessary,  will  often  suffice  to  diminish  the  volume  of  the  congested 
or  hypertrophied  uterus  and  gradually  to  dispose  it  to  resume  its 
normal  position. 

These  means  must  be  used  for  several  months  and  be  resorted  to 
again  and  again.  If  the  prolapsus  depends  on  a  sudden  distension  of 
the  ligaments,  and  has  been  produced  suddenly  in  a  young  woman,  in 
fact,  if  it  be  recent  and  acute,  the  same  means  may  suffice,  especially  if 
the  genu-pectoral  attitude  is  assumed. 

Electricity  and  the  cold  douche  exercise  on  the  suspensory  ligaments 
a  local  action,  the  association  of  which  with  general  hydropathy  and 
tonics  produces  excellent  effects.  If  electricity  is  tried  one  of  the 
poles  should  be  applied  to  the  cervix  and  the  other  to  the  groins  and 
sacral  region  at  the  point  of  attachment  of  the  utero-lumbar  ligaments. 
If  hydropathy  is  prescribed,  general  hydropathy  should  always  be 
combined  with  the  douche  or  spray  on  the  loins,  sides  and  groins  and 
the  treatment  should  be  continued  for  a  long  time.  When  nothing 
better  can  be  had  cold  sitz-baths  may  be  prescribed  for  one  minute  at 
a  time  and  repeated  five  or  six  times  in  the  day.  Although  there  is 
no  certainty  of  a  cure  being  obtained  from  this  kind  of  treatment,  it 
will  be  well  to  give  it  a  fair  trial  and  for  a  long  time  if  there  is  no 
contra-indication.  I  have  seen  it  produce  excellent  results.  I  am  in 
the  habit  of  seeing  a  lady  for  whom  I  prescribed  this  treatment  more 
than  twenty  years  ago  for  a  prolapsus  which  made  walking  impossible 
and  produced  terrible  attacks  of  hysteria ;  she  continued  the  treatment 
for  six  months,  and  since  that  time  she  has  had  no  serious  hysterical 
symptoms,  and  she  can  walk  as  far  and  almost  as  easily  as  before  she 
was  ill.     I  ought  to  add  that  she  could  never  bear  a  pessary. 

These  are  really  the  only  means  that  can  produce  in  the  tissues  a 
natural  modification  capable  of  overcoming  the  cause  of  the  descent. 
They  ought  always  to  be  used,  and  sometimes  exclusively,  especially  in 
cases  of  slight  prolapsus  that  are  recent  and  due  to  a  uterine  malady 
which  is  still  curable. 

B.  Palliative  mechanical  treatment  is  indicated  in  cases  of  long- 
standing prolapsus,  with  rupture  of  the  suspensory  ligaments,  lacera- 
tion of  the  perinseum,  cystocele,  rectocele,  &c.     The  mechanical  means 


376  UTEEINE   DISEASES   II<«    DETAIL 

of  retention  are  very  numerous,  but  in  this  apparent  wealth  we  have 
only  an  additional  proof  of  real  poverty.  I  do  not  mean  to  say  that 
any  one  of  these  means  does  not  answer  some  special  indication.  But 
the  contact  of  these  foreign  bodies  with  the  mucous  membrane,  the 
embarrassment  which  their  size  causes  in  the  cavity,  the  irritation,  the 
pathological  secretions  and  the  other  alterations  of  tissue  to  which 
their  presence  gives  rise,  the  trouble  which  their  introduction  causes  to 
patients,  owing  to  the  difficulty  which  they  have  in  introducing  them, 
the  shocks  felt  by  the  neighbouring  organs,  the  painful  pressure  which 
they  necessitate  on  other  parts,  all  go  to  prove  a  state  of  imperfection 
in  these  means  which  makes  them  intolerable  to  many  patients.  There- 
fore, as  a  rule,  they  should  frequently  be  withdrawn  from  the  vagina, 
not  only  for  the  sake  of  cleanliness  but  to  rest  the  organ,  and,  when  a 
tendency  towards  cure  shows  itself,  which  may  occur  when  there  is 
only  relaxation  without  laceration,  instruments  of  gradually  decreasing 
size  should  be  used  till  they  can  be  dispensed  with  altogether.  The 
pessary,  by  maintaining  the  organ  in  its  natural  place,  allows  the 
tissues  in  virtue  of  their  natural  elasticity  to  resume  their  normal 
size  and  resistance,  in  fact  gradually  to  effect  a  cure.  Therefore  it  is 
a  mistake  to  say  :  A  prolapsus  is  a  hernia,  and  a  pessary  is  a  bandage 
which  retains  it.  A  pessary  by  maintaining  the  reduction  places  the 
uterus  in  a  condition  to  recover,  if  that  be  possible,  a  contractility 
temporarily  suspended. 

The  choice  of  the  pessary  ought  to  depend  on  whether  the  vulva 
and  perinseura  are  intact  and  resistant  or  not. 

a.  When  the  v^ilva  and perinaum  are  intact,  when  the  contractility 
of  the  fibrous  and  muscular  tissue  of  the  vagina  has  not  disappeared, 
the  smallest  foreign  body  with  a  surface  sufficiently  soft  not  to  irritate 
the  mucous  membrane,  and  large  enough  to  fill  the  space  which  sepa- 
rates the  cervix  in  its  normal  position  from  the  perinseum  suffices  to 
sustain  the  uterus  in  its  normal  position. 

1.  The  simplest  and  often  the  best  of  all  these  pessaries  is  a  fine 
sponge  {see  Tig.  154,  p.  198),  or  if  that  cannot  be  had,  a  tampon 
saturated  in  an  astringent  or  styptic  solution  -}  the  sponge  should  be 
carefully  washed  every  day,  and  taken  out  for  the  night  when  the 
patient  is  in  the  horizontal  position.  Spherical  pessaries  are  in  their 
action  somewhat  like  sponge ;  they  press  equally  on  all  sides,  but  by 
dilating  the  vagina  in  every  direction  have  the  disadvantage  of  changing 
its  form  and  of  compressing  important  organs,  especially  the  bladder 
and  rectum. 

By  making  spherical  pessaries  elastic,  as  Gariel  has  done  {see 
Pig.  155,  p.  193),  they  can  more  easily  mould  themselves  to  the 
vaginal  cavity  and  multiply  their  points  d'appui  without  provoking 
pain.  They  have  been  covered  by  a  layer  of  amadou  to  make  contact 
with  the  vagina  less  trying,  and  when  resistance  of  the  perinseum  is 
defective,  they  may  be  kept  in  the  vagina  by  means  of  a  perinseal  pad 
kept  in  place  by  a  T  bandage.     With  the  view  of  avoiding  painful 

^  In  1853,  Tordjce  Barlcer  wrote  a  paper  on  the  treatment  of  procidentia  by 
the  use  of  tampons  soaked  in  a  solution  of  tannin,  which  is  quoted  by  Sims. 


DISPLACEMENTS  377 

pressure,  bung-shaped  pessaries  have  beea  invented  which  preserve  the 
form  of  the  vagina,  and  others  like  a  sandglass,  which,  from  the  hol- 
lowing out  of  their  central  part,  have  no  oihev  point  cVappui  than  the 
cervix  on  one  side  and  the  perinseum  on  the  other ;  unfortunately  the 
size  of  these  instruments  makes  them  intolerable. 

2.  The  difficulty  of  maintaining  these  pessaries  in  the  vagina  even 
when  the  vulva  offers  a  certain  amount  of  resistance,  and  the  import- 
ance of  avoiding  compression  of  the  rectum  and  bladder  have  led  to 
spherical  pessaries  being  transformed  into  discs  and  ovals  pierced  in 
the  centre  to  preserve  the  uterus  from  contact  with  them  and  to  facili- 
tate the  evacuation  of  mucus ;  they  have  also  been  hollowed  out  in 
front  and  behind  to  avoid  pressure  on  the  rectum  and  bladder.  Such 
has  been  the  origin  of  the  biscuit-shaped  or  figure-of-8  pessaries,  which 
are  introduced  longitudinally  and  afterwards  turned  round  in  the 
vagina,  so  that  their  greatest  diameter  is  transversal.  Lastly,  to 
avoid  distension  of  the  vagina  as  well  as  painful  pressure  on  bladder 
and  rectum  in  cases  where  the  resistance  of  the  perinseum  is  consider- 
able, cup-shaped  pessaries  with  a  short  stem  have  been  invented,  like 
those  of  Hervez  de  Chegoin,  Simpson,  &c.,  which  support  the  cervix 
in  their  cavity,  whilst  their  other  extremity  rests  on  the  perinseum. 
Besides,  however,  necessitating  the  resistant  perinseum,  these  retentive 
means  are  insufficient  for  a  displacement  like  prolapsus. 

3.  The  disadvantages  of  distension  of  the  whole  vagina  when  pushed 
beyond  certain  limits  have  led  German  gynecologists  to  try  to  support 
the  uterus  by  distending  the  upper  part  of  the  vagina.  This  is  the 
origin  of  the  new  pessaries  incorrectly  called  liysterophores ;  these 
hysterophores,  like  pessaries,  may  be  free  or  retained,  may  either  have 
their  two  points  d'appui  on  the  vagina  which  they  distend,  or  they 
may  support  the  vagina  by  means  of  an  external  point  d'apptii. 
Kilian's  elytromoclilion  was  the  first  one  invented.  To  make  the  in- 
troduction of  the  instrument  easier,  its  position  more  fixed  and  the 
divergence  of  its  extremities  more  constant,  Zwank  (of  Hamburg) 
invented  his  hysterophore,  composed  of  two  wings  with  stems  and 
furnished  with  a  hinge  in  the  centre,  which  allows  of  closing  the  wings 
in  introducing  the  instrument,  and  when  once  it  is  in  place  of  sepa- 
rating them  to  distend  the  vagina,  keeping  them  in  position  by  a  screw. 
Schilling  made  the  use  of  the  instrument  inconvenient  by  trying  to 
regulate  the  divergence  of  the  wings  by  means  of  a  vice  ;  but  Eulen- 
bourg  and  Savage  have  improved  it,  the  former  by  substituting  an 
india-rubber  ring,  the  latter,  a  tube  of  the  same  material  for  Zwank's 
screw  (Figs.  170,  171,  pp.  196,  197). 

4.  We  cannot  advise  the  use  of  any  of  these  means  excepting 
always  a  sponge,  a  tampon,  and  Gariel's  pessary,  which  are  useful 
in  some  cases,  especially  when  associated  with  astringent  applications  ; 
they  all  have  the  disadvantage  of  irritating  the  vaginal  and  uterine 
mucous  membranes,  and  of  taking  up  too  much  space  or  exercising 
painful  pressure  which  is  not  compensated  by  the  advantages  they 
offer.  This  cannot  be  said  of  Hodge's  lever  pessary,  vvhich  has  been 
still  further  improved  during  the  last  few  years.     This  is  the  best 


378 


OTEEINE    DISEASES   IX    DETAIL 


pessary,  both  wlien  the  prolapsus  is  recent  and  the  vagina  has  pre- 
served its  contractility  (which  is  apt  to  be  lost  by  the  use  of  the 


Fig.  259. — Hodge's  aluminium  pes- 
sary :  a,  antei'ior  transverse 
branch,  indented  on  a  level  with 
the  urethra ;  h,  transverse  pos- 
tero-superior  rounded  branch. 


Fig.  260. — Hodge's  pessaiy  in  place  ;  its 
form  is  less  sigmoid  than  in  Fig. 
259.  Evei-y  time  the  inferior  branch 
descends,  at  every  inspiration,  the 
upper  one  rises  and  raises  the  womb 
along  -with  the  posterior  vaginal 
cid-de-sac. 


previously  named  instruments  owing  to  their  excessive  distension 
of  the  vagina),  and  when  the  vagina  has  lost  this  contractility,  when 
the  perinseum  is  weakened,  and  when  we  must  try,  by  keeping  the 
uterus  in  its  place,  to  restore  the  contractility  and  resistance  of  these 
organs  as  well  as  of  the  suspensory  hgaments.  In  the  first  place 
instead  of  distending  the  vagina  and  of  being  fixed  in  it^  the  instru- 
ment is  mobile,  rising  and  falling  at  every  inspiration.  It  has  the 
sigmoid  form,  and  its  size  may  be  determined  approximately  by  a 
measurement  made  with  the  finger.  The  length  ought  to  be  such 
that  when  the  postero-superior  limb  is  at  the  further  end  of  the  pos- 
terior vaginal  cul-de-sac,  without  touching  the  uterus,  the  antero- 
inferior one  is  behind  the  symphysis,  above  the  meatus.  It  is  intro- 
duced by  pushing  the  posterior  limb  fi.rst  upwards  then  backwards,  so 
that,  guided  by  the  finger,  it  reaches  the  posterior  vaginal  cul-de-sac, 
when  the  anterior  limb  should  be  raised  and  brought  behind  the 
pubis.  When  in  place  its  action  is  as  follows  :  during  inspiration, 
when  the  intestines  are  pushed  against  the  uterus  and  bladder  and 
cause  the  anterior  vaginal  wall  to  descend,  the  antero-inferior  limb  of 
the  pessary  which  rests  on  this  wall,  follows  it  in  this  movement  and 
descends  a  little  ;  the  postero-superior  limb  necessarily  rises  in  an 
opposite  direction,  raising  the  roof  of  the  vagina  and  with  it  the 
uterus,  the  cervix  being  raised  and  directed  backwards  whilst  the 
fundus  is  inclined  forwards  (if  care  has  been  taken  to  reduce  it  pre- 
viously) ;  now  when  the  fundus  is  anteverted,  it  is  impossible  that  it 
can  fall.  The  action  of  the  pessary  is  helped  by  the  posterior  wall  of 
the  vagina  and  the  perinseum  constituting  a  firm,  thick,  elastic  tissue 
which,  partly  owing  to  its  contractility,  partly  under  the  influence  of 


DISPLACEMENTS  379 

atmospheric  pressure,  is  maintained  in  immediate  contact  with  the 
anterior  wall  and  prevents  prolapsus.  This  pressure  is  exercised 
naturally  on  the  upper  limb  of  the  pessary  embraced  by  the  vagina. 
The  vulval  sphincter  by  its  contraction  also  assists  in  supporting  the 
instrument.  The  patient  ought  to  wear  her  pessary  continuously; 
it  is  unnecessary  to  withdraw  it  at  night,  it  does  not  prevent  coitus, 
nor  even  conception  and  pregnancy,  which  occur  frequently,  although 
it  is  better  to  avoid  marital  intercourse  while  wearing  it.  Its  light- 
ness and  its  cleanliness,  which  is  easily  maintained  by  warm  vaginal 
injections  made  twice  a  day  with  a  weak  solution  of  carbolic  acid, 
exempt  its  use  from  all  inconvenience.  It  only  requires  to  be 
removed  occasionally,  to  prevent  accidents  and  allow  of  local  exami- 
nation. Therefore  it  is  the  first  pessary  that  should  be  tried,  especi- 
ally when  the  prolapsus  is  recent,  and  when  it  is  not  accompanied  by 
any  lesion  of  the  vagina  or  perinseum.  When  it  fails  we  may  have 
recourse  to  other  kinds  of  pessaries  which  we  are  about  to  describe ; 
but  we  must  not  expect  more  than  a  palliative  cure  from  them,  no 
more  than  from  a  truss. 

h.  When  the  vulva  is  enlarged,  the  perinceum  thin  or  destitute  of 
elasticity/,  and  even  the  four chette  lacerated,  the  defective  resistance 
of  the  perinseum  must  necessarily  be  supplied  by  a  pad  which  replaces 
it,  or  by  means  which  keep  the  uterus  raised  by  supporting  it  either 
directly  or  indirectly. 

1.  A  simple  perinceal pad  (Fig.  152,  p.  192)  furnished  with  straps 
fastened  to  a  strong  belt  or  pelvic  corset  may  suffice  to  maintain  the 
uterus  in  the  pelvic  cavity,  thus  converting  the  painful  prolapsus  into 
a  descent  that  can  be  tolerated.  The  pad  ought  to  be  of  wood,  ivory, 
gutta  percha  or  horsehair,  and  sufficiently  thick ;  the  straps  of  strong 
leather  and  cylindrical,  kept  in  place  behind  and  before  by  buckles 
placed  as  near  the  centre  as  possible ;  the  belt,  a  piece  of  ticking  lined 
with  chamois  leather  with  a  padded  metallic  plate,  resting  above  the 
pubis  (Hull),  or  rather  on  the  upper  part  of  the  sacrum  (Ashburner), 
the  firm  and  mild  compression  of  which  considerably  relieves  lumbar 
pain.  I  have  seen  these  means  succeed  even  in  cases  of  hypertrophy 
of  the  cervix,  the  replacing  of  which  could  be  eff'ected  without  pain. 
By  not  distending  the  vagina  it  has  the  advantage  of  enabling  it  to 
recover  its  elasticity. 

2.  The  inadequacy,  however,  of  this  means  has  suggested  the  idea 
of  seeking  externally  for  the  points  d'apptci  which  are  refused  by  the 
vulva  and  perinseum  to  c^ip- shaped  pessaries,  which  seem  the  best  fitted, 
especially  when  elastic,  to  support  the  uterus  directly,  without  distend- 
ing or  pressing  painfully  on  the  parts  situated  in  the  neighbourhood 
or  below  it.  This  is  the  origin  of  all  the  cup-and-hall  pessaries  on 
which  the  cervix  rests,  including  those  of  Bauhin,^  Suret,  Desormeaux 
and  Amussat^  {see  Fig.  180,  p.  199J,  as  well  as  those  of  Bourjeaurd, 

1  Bauhin,  A'^'pendix  ad  partum  ccesareum  Bosseti,  quoted  by  Sabatiev, 
Memoires  de  I' Acad,  de  chir.,  t.  iii,  j).  .374. 

^  Bourgeiy  and  Jacob,  Medecine  operatoire,  t.  ii,  p.  319  and  pi.  72.  Paris 
1840. 


380  UTERINE    DISEASES    IN    DETAIL 

Gabriel,  Coxeter,  &c.,  all  of  which  are  pierced  with  an  opening 
in  the  centre  for  the  discharge  of  fluids  {see  Fig.  181,  p.  199),  and 
attached  to  a  belt  by  flexible  supports,  like  those  of  Bourjeaurd,  or  by 
rigid  stems  made  mobile  by  the  ductility  of  the  metal  or  by  the  play  of 
certain  articulations  of  the  stem  which  bears  the  cup  destined  to  sup- 
port the  uterus,  like  those  of  Lazarewitch^  and  other  makers. 

3.  Lastly,  the  difficulty  of  supporting  the  uterus  directly  and  the 
drawback  of  the  cervix  resting  (especially  when  it  is  diseased)  upon  a 
hard  body  which  irritates  it,  ulcerates  it,  or  makes  it  bleed,  has  sug- 
gested the  idea  of  using  indirect  points  d^appui  which,  by  raising  the 
vagina,  maintain  the  uterus  also  m  its  place. 

One  of  the  simplest  and  most  convenient  instruments  of  this  kind  is 
Scanzoni^s  pessary  on  a  movable  pivot,  the  stem  of  which  supports  a 
polished  sphere  and  has  its  point  d''app%i  below  on  a  T  bandage  by 
means  of  a  ball-and-socket  joint  {see  Y\g.  183,  p.  199).  The  instru- 
ments called  retained  hysterophores  are  also  of  this  kind.  These  are 
bent  stems  taking  their  point  d'appui  on  the  plate  of  a  hypogastric 
belt,  and  terminating  in  a  sphere,  a  ring  or  a  plate  sufficiently  elastic 
and  resistent  to  keep  the  anterior  vaginal  cul-de-sac  raised  without 
hurting  it.  Saviard^s  pessary  and  the  hysterophores  of  Roser,  Scauzoiii, 
Charriere  and  Becquerel  are  of  this  kind  {see  Fig.  182,  p.  199). 

c.  Surgical  treatment  or  radical  cure. — This  consists  in  modifica- 
tions efi'ected  on  the  perinseum,  vulva  and  vagina  by  various  operations, 
with  the  object  of  exercising  on  the  reduced  uterus  natural  and  per- 
manent retention.  These  operations  aim  at  closing  or  contracting 
the  passages  which  allow  the  escape  of  the  prolapsed  uterus. 

a.  Closing  the  vulval  ring  completely  may  be  tried  in  cases  where  the 
patient  is  aged,  the  uterus  obliterated,  &c.  It  may  be  eft'ected  by  one 
of  the  means  about  to  be  described  as  used  simply  to  contract  it,  or  by 
the  operation  of  Vidal  de  Cassis  for  obliteration  of  the  vagina  in  cases 
of  vesico-vaginal  fistula.  The  vulva  may  be  incompletely  closed  by  the 
union  of  the  labia,  i.  e.  by  infibulation.  This  operation  was  success- 
fully performed  by  Schietfer  in  1856  by  means  of  a  trocar  and  leaden 
thread.  Klein ^  repeated  it,  passing  two  threads  of  lead  and  failed  ; 
the  uterus  escaping  near  the  commissure,  was  hurt  and  strangulated  by 
the  thread.  In  1859  Aran^  performed  it  four  times;  one  case  relapsed, 
another  was  followed  by  strangulation;  the  result  of  the  two  others  is 
unknown. 

h.  Contraction  of  the  passages  which  afford  escape  to  the  prolapsus 
may  be  effected  :  1,  on  the  vulva  or  on  the  vagina  in  the  neighbourhood 
of  the  vulva ;  2,  on  the  vulva  and  perinseum  ;  3,  on  the  vagina  only. 

1.  Contraction  of  the  vulva  {episiorap/iy)  is  obtained  by  the  dissec- 
tion and  suture  of  the  three  inferior  quarters  of  the  labia,  an  operation 
suggested  by  Mende  and  executed  by  Fricke,  of  Hamburg,^  in  1833. 

1  Coup  d'oeil  sur  les  changements  de  forme  et  de  position  de  V  uterus  et  sur 
iy.ur  traitement.  Paris,  1862. 
-  Deutsche  Klinik,  1856. 
3'„0p.  cit.,  p.  1047. 

•*  jtinnalen  der  chirurgischen  Ahtheilungen  des  allgemein.  KranJccnhauses  in 
Hamb-arg,  Bd.  2,  S.  142.  Gottingen,  1833. 


DISPLACEMENTS  381 

Adhesion  is  not  always  complete  ;  disunion  of  the  fragments  below  has 
been  observed^  and  consequently  the  persistence  of  an  opening  against 
the  fourchette.  This  accident  is  not  exactly  unfavorable,  for  it  pre- 
vents the  surfaces  which  have  been  brought  together  from  being  sepa- 
rated by  hsemorrhage  or  suppuration,  as  has  happened  in  other  cases  ; 
besides,  the  perinseal  opening,  though  narrow  enough  to  prevent  the 
escape  of  the  uterus,  is  sufficient  for  the  menstrual  discharge,  and  has 
been  dilated  enough  to  allow  of  the  passage  of  the  foetus  in  labour,  as 
in  the  case  described  by  Platt.^  Unfortunately  the  success  of  this 
operation  is  far  from  being  certain.  If  it  has  succeeded  once  with 
Loscher  and  once  with  Knorre,  it  has  failed  once  with  Velpeau  and 
Paget  and  four  times  with  Scanzoni,  once  with  Koux,  and  several  times 
with  Stoltz,  the  labia  distending  without  rupturing  till  they  allowed 
the  tumour  to  escape  anew.  Therefore,  although  recommended  by 
DiefPenbach,  episioraphy  was  definitely  condemned  by  Kilian.  Perhaps 
it  would  have  been  successful  if  performed  as  Kuschler  advised,  deep 
suture  associated  with  superficial  suture,  as  in  perineoraphy. — Con- 
traction of  the  vulval  portion  of  the  vagina,  inferior  elytroraphy ,  per- 
formed by  Malgaigne  in  1837,  did  not  succeed.  Simon  also  failed  in 
performing  elytro-episiorapliy,  i.  e.  juxtaposition  and  suture  after 
dissection  of  the  vulva  and  lower  portion  of  the  vagina. 

%.  Contraction  of  the  vulva  and  perinaeum,  episio-perineoraphy , 
consists  in  the  greatest  extent  of  juxtaposition  by  extending  the  incisions 
from  the  vulva  to  the  perinseum,  and  in  the  increase  of  the  depth  and 
resistance  of  the  cicatrix  which  contracts  the  vulva  behind.  The  resto- 
ration of  the  perineeum,  far  superior  to  partial  obliteration  of  the  vulva, 
restores  to  the  pelvic  organs  the  support  of  which  they  had  been 
deprived  by  an  accident,  and  seems  to  constitute  an  essentially  cura- 
tive measure.  The  operation  consists  in  removing  a  portion  of  tissue 
in  the  shape  of  a  horse- shoe  and  uniting  the  two  sides  by  a  double  set 
of  sutures,  consisting  of  three  deep  and  three  superficial  stitches. 
Cases  of  relapse  seem  to  have  been  exceptional  and  to  have  de- 
pended on  the  extreme  smallness  of  the  uterus ;  there  was  no  death. 
Breslau  does  not  excise  the  dissected  fragments,  but  turns  them 
inside  out,  placing  them  in  juxtaposition,  like  a  spur  or  beak,  in 
front  of  the  perinseum,  a  method  which  gives  more  height  to  the  plane 
of  reunion.  Hilton^  and  Oldham^  have  added  section  of  the  anal 
sphincter  to  facilitate  the  autoplasty  and  to  extend  the  perinseum. 
This  operation,  although  inaugurated  in  France  by  Stoltz,  of  Strasburg, 
has  been  performed  most  frequently  in  Germany  and  England,  and 
principally  by  Baker  Brown,*  who  performs  similar  operations  for 
cystocele,  rectocele,  and  rupture  of  the  perinseum.  In  1861  this  surgeon 
had  operated  on  forty-one  patients  by  this  method :  the  result  was  thirty- 
eight  cures,  improvement  in  two  cases,  one  relapse.     Unfortunately 

'   Gazette  viedicale,  1836,  p.  16. 
-  Guy's  Hospital  Reports,  2nd  series,  vol.  viil,  1854. 
^  Med.  Times  artd  Gazette,  1857. 

''  On  Surgical  Diseases  of  Women,  2nd  edit.,  p.  96.  London,  18(51. — See 
also  Savage,  Lancet,  vol.  i,  p.  164,  1858. 


382  UTEEINE    DISEASES    IN    DETAIL 

he  does  not  say  how  long  it  is  since  his  patients  were  operated  on; 
and  as  firmcess  of  the  perinseum  and  existence  of  the  hymen  do  not 
prevent  uterine  prolapsus,  we  may  be  certain  that  restoration  of  the 
perinseum  does  not  suffice  to  cure  it.  Kuckler,  of  Darmstadt,  and  Anger 
pursue  a  much  surer  method  ;  the  latter  proceeds  by  dissecting  off  the 
mucous  membrane  of  the  labia  and  the  neighbouring  part  of  the  vagina, 
and  both  carry  the  dissection  and  suture  close  to  the  urethral  orifice. 
Anger  has  ascertained  that  cure  was  persistent  eighteen  months  after- 
wards ;  this  operation  is  therefore  successful,  but  the  escape  of  vaginal 
mucous  is  difficult  and  coitus  impossible. 

3.  Stricture  of  the  vagina  has  been  produced  by  suppuration  and 
by  the  formation  of  retractile  cicatricial  tisme  (Hamilton)^,  in  imi- 
tation of  the  traumatic  cicatrices  which  obliterate  or  contract  the 
vagina.  This  suppuration  and  consequent  cicatrisation  are  brought 
about  by  the  simple  excision  of  a  zone  of  vaginal  mucous  membrane 
all  round  the  tumour,  as  proposed  by  Eomain  Gerardin  -^  or  by  the 
excision  of  a  piece  of  the  vagina  and  uterus  at  the  top  of  the  tumour, 
as  performed  by  Mayer,  an  excision  which  may  necessitate  the  applica- 
tion of  the  actual  cautery  to  arrest  the  hsemorrhage;  or  by  the 
excision  of  several  fragments  round  the  neck  (Cruveilhier),  in  imitation 
of  Dupuytren^s  quadrangular  excision  of  portions  of  tissue,  to  cure 
anal  prolapsus.  The  formation  of  a  cicatrix  may  also  be  procured  by 
cauterisation  with  nitrate  of  silver  (Cruveilhier),  or  acid  nitrate  of 
mercury  (Laugier),  the  actual  cautery  (Velpeau),  or  sulphuric  acid 
(Selnow) ;  in  all  cases,  however,  cauterisation  is  either  insufficient  or 
dangerous.  Therefore  this  means  has  never  been  tried  for  complete  ob- 
literation of  the  vagina  as  proposed  by  Gerardin.  The  ligature  applied 
to  one  or  several  portions  of  the  raised  vaginal  mucous  membrane,  as 
to  the  pedicle  of  a  polypus,  as  proposed  by  Blasius,^  or  the  wrinkled 
suture  proposed  by  Bellini  under  the  name  of  colpodesmorajphy ,  are 
equivalent  to  suture  after  excision.  Lastly,  joincement,  simple  or  by 
caustics,  intended  to  provoke  gangrene  in  several  folds  of  the  vaginal 
mucous  membrane,  which  are  retained  between  the  teeth  of  strong 
serre-fines,  has  been  proposed  and  practised  by  Desgranges,  of  Lyons. 
This  surgeon  has  pubhshed  several  successes  due  to  the  application 
of  this  method.  Nelaton  has  also  had  successful  cases.  The  means 
is  ingenious,  but  the  operation  frequently  requires  to  be  repeated,  and 
is  not  without  danger.  This  is  the  drawback  of  almost  all  the  opera- 
tions just  described ;  they  are  liable  to  cause  serious  dangers  in 
trying  to  cure  an  infirmity  which  is  usually  unattended  with  any, 
and  to  substitute  a  deformity  admissible  in  old  women,  but  which  in 
the  young  may  be  the  cause  of  pains  and  fresh   dangers,  from  the 

^  Cooper's  Dictionary  of  Surgery. 

'  Arch.  gen.  de  med.,  viii,  132.  Paris,  1824. 

3  Neue  Operationsmethode  heim  GehdrmuUervorfall  mittels  hreisformiger 
Ligaturen.  In  a  woman  of  twenty- four  years  Blasius  applied  four  along  the 
vagina,  the  first  in  the  neighbourhood  of  the  uterus,  the  second  near  the  vulval 
orifice,  the  two  others  in  the  interval.  It  is  needless  to  say  that  the  result 
cannot  be  counted  upon.  Frenssisclie  Vereinszeitung,  1844,  n.  41.  Schmidt's 
Jahrbiicher.  Bd.  45,  S.  52. 


DISPLACEMENTS  383 

obstacle  which  it  puts  in  the  way  of  the  accomplishment  of  the 
functions  of  the  vulvo-uterine  canal,  especially  that  of  delivery. 
These  operations  I  think  are  only  indicated  when  extreme  relaxation 
of  the  vulva  and  vagina,  cystocele  or  rectocele,  occur  not  only  as  con- 
secutive elements  and  secondary  complications,  but  as  principal 
elements  and  serious  complications  of  prolapsus.  If  narrowing  of 
the  vagina  is  decidedly  indicated,  as  alone  able  to  prevent  prolapsus, 
suture  of  this  membranous  canal  on  one  or  both  of  its  walls  is  pre- 
ferable to  all  these  operations.  This  suture  is  known  by  the  name  of 
elytrorapliy  or  colporaphy . 

Elytrorapliy  or  colporaphy  is  an  operation  which  consists  in  dissect- 
ing off  a  band  of  mucous  membrane  from  the  anterior  or  posterior 
vaginal  wall  between  two  longitudinal  incisions,  and  bringing  together 
the  edges  of  the  wound  with  points  of  suture.  Marshall  Ball^  invented 
this  operation.  Heming,  quoted  by  Boivin  and  Duges,^  performed  it 
successfully  in  1831,  Ireland^  modified  it  by  making  the  incisions  on 
the  side  of  the  tumour  to  avoid  wounding  the  bladder.  A.  Berard, 
who  gave  it  its  name,  performed  it  several  times  unsuccessfully. 
Velpeau  fixed  the  threads  before  finishing  the  incision  and  repeated 
the  operation  before  and  behind  without  more  success.  Scanzoni 
performed  it  thirteen  times  without  success.  Therefore,  although 
Dieffenbach  has  modified  the  proceeding  by  removing  two  bands  in 
place  of  only  one  oval  one  as  formerly,  and  by  repeating  the  operation 
several  times  in  a  different  spot,  if  the  tumour  is  reproduced,  the 
majority  of  surgeons  regard  this  method  of  treatment  as  useless, 
besides  being  attended  with  danger.  Colporaphy,  however,  has  been 
revived  after  undergoing  several  modifications  ensuring  for  it  more 
success  in  the  future  than  it  has  had  in  the  past. 

a.  Anterior  elytroraphy. — Marion  Sims*  in  place  of  making  the 
suture  after  having  denuded  a  large  oval  surface  of  the  anterior  vaginal 
wall  (as  in  his  first  attempts),  has  improved  the  operation  by  dissect- 
ing off  the  anterior  wall  a  portion  of  mucous  membrane  in  the  form  of 
a  trowel  (Fig.  261),  so  as  to  form  a  real  fold,  the  upper  ends  of  which 
(e  d)  are  brought  into  contact  and  so  directly  support  the  neck  of  the 
uterus.  In  a  case  where  the  rest  of  the  suture  had  failed,  Emmet ^ 
ascertained  that  the  union  of  the  surfaces  (c  d,  Eig.  261)  and  the  con- 
sequent narrowing  of  the  vagina  in  the  anterior  cul-de-sac  sufficed  to 
maintain  the  uterus  in  place. 

The  performance  of  elytrorapliy  by  this  method  is  a  delicate  opera- 
tion. The  patient  lies  on  her  back  or  on  the  left  side.  Denudation 
and  suture  being  usually  performed  on  the  anterior  vaginal  wall, 
the    posterior   wall   and    the    perinseum    are    depressed    by    a    Sims' 

'  He  removed  a  band  of  mucous  membrane  the  length  of  the  vagina  and 
12  mm.  in  breadth,  and  united  the  edges  of  the  wound  by  sutures ;  two  years 
afterwards,  in  1833,  Vincent  found  the  uterus  and  vagina  in  position. 

^  Translation  of  Heming's  paper,  1834,  p.  53. 

^  Gazette  med.,  1832. 

*  Op.  cit ,  p.  310. 

*  A  Radical  Operation  for  Procidentia  Uteri,  New  York  Medical  Journal, 
April,  lS(i5. 


384  TJTEEINE    DISEASES    IN    DETAIL 

speculum.  I  then  fix  in  the  anterior  lip  of  the  cervix  the  two 
terminal  ends  of  a  catheter,  the  convexity  of  which  depresses  the  ante- 
rior vaginal  wall  towards  the  bladder ;  the  curve  of  the  catheter  is 


Fig.  261. — Elytroraphy  as  performed  by  Sims,  a,  h,  c,  d,  bleeding  surface  in  the 
form  of  a  trowel ;  /,  central  part  of  the  anterior  vaginal  wall,  which  will 
be  enclosed  by  bringing  the  sides  of  the  wound  a  c,  b  d,  together ;  e,  com- 
munication of  the  farther  cavity/  with  the  anterior  utero-vaginal  groove 
insufficient  to  allow  the  passage  of  the  cervix.  It  will  be  seen  that  the 
meatus  is  below,  the  patient  being  in  the  genu-pectoral  position. 

buried  under  the  lateral  folds  formed  by  the  mucous  membrane,  and 
these  folds  indicate  very  exactly,  where  they  meet  in  the  median  line, 
the  spot  where  the  mucous  membrane  ought  to  be  dissected,  so  that 
these  folds  may  be  afterwards  brought  into  contact.  I  then  pass  a 
solution  of  nitrate  of  silver  over  these  folds  and  afterwards  one  of  salt, 
which  whitens  them  and  allows  me  to  mark  out  beforehand  and  very 
exactly  the  surface  which  has  to  be  denuded ;  in  order  to  trace  the 
transverse  line  of  denudation  (e  d)  the  cervix  is  drawn  downwards. 
In  tracing  the  branches  of  the  V  care  must  be  taken  to  make  them 
neither  too  divergent  nor  too  close  together.  I  then  reproduce  the 
cystocele,  which  makes  denudation  easier ;  a  few  points  of  suture  may 
even  be  made  before  reducing  anew.  These  sutures  should  be  placed 
transversely,  commencing  from  below,  and  the  uterus  should  be  pushed 
backwards  with  the  sound  till  those  nearest  the  cervix  are  passed. 
The  sutures  must  embrace  the  whole  of  the  denuded  tissue  (c  d)  to  the 
exclusion  of  the  undenuded  portion  (e),  where  it  is  important  to  leave 
a  canal  for  the  discharge  of  the  mucous  or  purulent  secretions  which 
may  accumulate  in  the  bag  (/).  The  cervix  should  be  supported 
by  the  catheter  till  all  the  sutures  have  beoi  closed  and  tightly 
fastened.     The  patient  should  be  in  the  dorsal   position  and  remain  in 


DISPLACEMENTS 


385 


bed  for  several  days  or  even  weeks ;  it  is  well  to  use  the  catheter  for 
some  days  and  produce  constipation  by  opiates.  The  lower  sutures 
may  be  withdrawn  at  the  end  of  eight  or  ten  days,  the  upper  ones  in 
a  fortnight. 

b.  Posterior  colporaphij . — xiccording  to  American  surgeons,  ely- 
troraphy  should  most  frequently  be  practised  on  the  anterior  vaginal 
wall,  because  cystocele  usually  complicates  procidentia  uteri.  As, 
however,  the  artificial  support  to  the  uterus  is  of  more  consequence 
than  the  complications  of  cystocele  or  rectocele,  we  are  not  surprised 
that  Siuion,  of  Heidelberg  (thinking  it  better  to  strengthen  the  poste- 
rior wall  of  the  vagina  in  order  to  make  it  a  support  for  the  uterus  and 
the  anterior  wall),  should  have  substituted  posterior  elytrorapliy  or,  to 
use  his  own  expression,  posterior  colporaphy^  for  Sims's  operation.  By 
means  of  a  broad  fenestrated  speculum  which  dilates  the  vagina  he 
removes,  with  scissors  or  bistoury,  a  portion  of  the  mucous  membrane 
and  subjacent  tissue  to  within  about  an  inch  of  the  vaginal  insertion  of 
the  neck.  The  upper  extremity  of  the  denuded  surface  ought  not  to 
be  pointed,  but  almost  square,  so   that  after  cicatrisation  has  taken 


Fia.  262. — Colpo-perineorapliy  of  Simon  and  Hegar  :  c  p  E,  juxtaposition 
of  the  right  and  left  bleeding  surfaces  of  the  vagina  and  perinseum  kept 
in  contact  by  alternate  long  and  short  sutures,  at  the  upper  part  a  pro- 
jecting fold  of  the  vagina  makes  a  supporting  surface  for  the  cervix ; 
E,  vagina  ;  c  u,  vaginal  portion  of  the  cervix  ;  v,  bladder  ;  e,  rectum. 

place  there  is  a  kind  of  bag  above  the  cicatrix  which  receives  and 
retains  tbe  cervix ;  a  very  practical  precaution  without  which  the 
cervix  would  penetrate  into  the  narrowed  canal,  would  insinuate  itself 
into  it  like  a  wedge,  and  by  gradually  dilating  it  would  eventually 
make  its  way  through  it  and  reproduce  the  prolapsus.  Below,  the 
posterior  portion  of  the  labia  must  be  denuded,  so  that  by  uniting 

'  Hegar  and  Kaltcnbach,  Die   operative  Gijnaekolocjie  mil  Einschluss  dev 
gynaehologischen  Untersuchungslehre,  S.  399,  401.  Erlangen,  1874. 

25 


386 


UTERINE    DISEASES    IN    DETAIL 


them  there  may  be  an  elongated  perinseum,  prolonged  forwards,  forming 
a  curve  terminated  by  a  spur  which  forms  an  extended  point  d'appui. 
The  opposite  borders  of  the  wound  are  brought  together  by  suture, 
and  by  the  union  of  the  two  surfaces  a  firm  and  dense  cicatricial  band 
is  obtained,  which  occupies  almost  the  whole  length  of  the  posterior 
vaginal  wall.  The  vagina  is  not  only  narrowed,  it  is  also  rigid  and 
sufficiently  thick  to  support  its  own  weight  and  that  of  the  uterus.^ 

I  may  just  mention  lateral  and  bilateral  elytroraphy ,  which  may  be 
suitable  exceptionally  to  a  specially  broad  vagina,  and  which  have  been 
tried  by  some  operators.  I  should,  however,  always  prefer  colpoperi- 
neoraphy  or  Lefort^s  operation,  or,  as  a  last  resource,  occlusion  of  the 


vaojma. 


c.  Median  colporapTiy  of  the  vagina  has  recently  been  performed  by 
Leon  Lefort.^  The  uterus  being  outside  the  vulva,  a  portion  of  mucous 
membrane  is  dissected  off  each  of  the  vaginal  walls  from  their  middle 
part,  about  six  centimetres  long  and  two  wide.  The  uterus  is  reduced 
sufBciently  to  bring  into  contact  the  uterine  extremities  of  these  two 
denuded  surfaces,  and  three  sutures  are  applied  to  this  transverse 
border,  uniting  the  anterior  and  posterior  vaginal  walls  in  a  linear 
direction.  The  union  of  the  lateral  borders  is  effected  afterwards  by 
passing  a  metallic  thread  on  each  side,  first  through  the  border  of  the 
anterior  denuded  surface,  and  then  through  the  corresponding  border 
of  the  posterior  surface ;  a  thread  being  placed  in  the  same  way  on 

'  The  Kolpoperineoplasty  of  Bischoff,  of  Bale,  described  by  Banga  (Bale, 
1875),  is  very  similar  to  this.  It  has  the  advantage  not  only  of  narrowing  the 
vagina  behind,  but  of  curving  it,  changing  its  direction  by  bringing  the  axis 
forwards.  Hegar's  Colpoperineoraphy  (op.  cit.,  p.  407,  et  seq.)  is  a  modifi- 
cation of  Simon's. 

^  Bulletin  general  de  therapeutique,  t.  xcii,  p.  337,  1877. 


DISPLACEMENTS  387 

the  opposite  border  and  at  the  same  height,  it  suffices  to  fasten  these 
two  sutures,  in  order  to  increase  the  reduction  of  the  uterus  bj  bring- 
ing the  opposite  vaginal  walls  together.  This  reduction  is  finished  in 
proportion  as  the  sutures  are  fixed,  and  when  the  two  borders  of  the 
denuded  surfaces  have  been  united  in  their  whole  length  reduction  is 
complete.  The  threads  that  have  served  for  suture  of  the  transverse 
border  nearest  the  uterus  being  hidden  in  the  upper  part  of  the 
vagina,  are  not  easily  accessible  when  union  is  effected  some  days 
afterwards ;  therefore  they  should  be  left  long,  so  that  they  can  be 
easily  seized  when  they  have  become  free.  In  his  first  case  Lefort 
completed  his  operation  hj  perineorapki/,  which  seemed  to  him  necessi- 
tated by  the  relaxation  of  the  vulva.  Median  colporaphy  has  the  ad- 
vantage of  not  preventing  coitus,  while  placing  in  the  vagina  an 
obstacle  which,  from  its  position,  ought  to  prevent  a  return  of  the  pro- 
lapsus better  than  any  other  operation. 

d.  Obliteration  of  the  vagiyia, — Obliteration  of  the  upper  part  of 
the  vagina  is  the  only  means  of  preventing  the  recurrence  of  prolapsus 
in  an  old  woman.  We  must  not,  however,  ignore  the  accompanying 
evils  :  that  marital  intercourse  is  absolutely  prevented,  and  that  the 
cervix  is  enclosed  behind  a  transverse  partition  of  the  vagina,  where  it 
is  soon  surrounded  by  an  accumulation  of  mucus  and  pus,  which 
macerates  the  epithelium  and  causes  ulceration  and  degeneration. 

e.  As  for  amputation  of  the  cervix,  by  which  Huguier  has  proposed 
to  treat  prolapsus  in  cases  of  hypertrophic  elongation  of  the  neck,  I 
shall  refer  to  it  when  we  come  to  hypertrophy  of  the  uterus. 

I  have  performed  all  these  operations  with  a  relative  success,  which 
enables  me  to  recommend  them.  I  speak  of  colporaphy  and  peri- 
neoraphy.  In  eight  patients  I  have  tried  to  narrow  the  vagina  by 
suture ;  this  narrowing  in  three  cases  was  effected  on  the  anterior 
vaginal  wall,  in  five  others  on  the  posterior  wall  and  the  perinseum. 
All  these  patients  were  able  to  resume  the  exercise  and  occupations 
which  they  had  been  forced  to  abandon.  JFour  of  them  did  not 
require  to  use  any  instruments;  the  four  others,  including  those 
operated  on  by  anterior  elytroraphy,  had  to  continue  the  use  of 
a  belt  with  perinseal  pad  to  support  the  uterus;  this  organ  did 
not  seem  to  have  any  tendency  to  escape,  but  the  belt  and  pad 
greatly  facilitated  exercise.  I  have  not  yet  had  occasion  to  try 
Lefort's  method,  but  I  should  not  hesitate  to  do  so,  adding  perineo- 
raphy  to  his  median  colporaphy,  if  the  gravity  of  the  evil  involved 
the  necessity  of  giving  more  strength  and  resistance,  by  an  increase  of 
thickness,  to  the  support  of  the  uterus.  Posterior  colporaphy  seems 
to  me  theoretically  preferable,  and  my  practice  has  justified  this  theory ; 
I  should  therefore  advise  it  when  there  is  reason  for  attempting  a 
radical  cure  of  these  maladies.  If  the  cystocele  has  not  yielded  to  this 
operation,  anterior  colporaphy  may  be  added.  If  hypertrophic  elonga- 
tion of  the  cervix  complicates  prolapsus,  amputation  of  the  cervix  must 
be  performed.  But  even  when  justified  in  performing  these  three 
operations  on  the  same  patient,  as  Tracy  of  Melbourne  did,  we  must 
beware  of  doing  so  at  one  sitting  as  he  did ;  a  considerable  interval 


388  UTEEIXE    DISEASES    IN    DETAIL 

should^  on  the  contrary^  be  placed  between  them.  I  do  not  speak  of 
perineoraphy,  which  is  evidently  included  in  posterior  colporaphy  in 
Simon's  operation. 

Before  undertaking  any  of  these  operations  the  patient  should  for 
some  time  previously  assume  the  decubitus  which  is  most  favorable  to 
reduction  ;  it  is  wonderful  what  amelioration  is  obtained  by  this  simple 
means^  which  greatly  lessens  the  gravity  of  the  operations  that  have 
to  be  performed, 


Deviations 

Deviations  are  changes  in  the  direction  of  the  uterus^  or  in  the 
relations  of  its  locgitudinal  axis  vrith  the  brim,  the  pelvic  cavity,  and 
the  viscera  contained  in  it.  When  this  change  is  slight  it  takes  the 
name  of  inclination,  and  of  obliquity  when  lateral;  when  more  marked 
that  of  deviation,  and  when  still  more  marked  that  of  version. 

These  three  expressions  designate  the  various  phases  through  which 
the  uterus  passes  before  reachiug  the  last  degree  of  deviation.  At  first 
slightly  inclined  in  one  direction  the  axis  of  the  uterus  deviates  more 
and  more  from  its  normal  direction,  till  the  organ  is  completely  turned 
upon  one  of  its  surfaces  or  sides,  afl'ecting  a  horizontal  direction,  and 
with  its  fundus  looking  forwards  or  backwards,  to  the  right  or  to  the 
left,  sometimes  even  looking  downwards  as  well  as  backwards,  whence 
the  name  of  version  {veriere). 

The  deviations  receive  their  special  names  from  the  side  of  the 
cavity  towards  which  the  fundus  is  directed,  the  cervix  always  taking 
the  opposite  direction.  If  the  fundus  inclines  forwards  and  down- 
wards the  cervix  looks  backwards  and  upwards;  if  it  inclines  back- 
wards the  cervix  looks  forwards.  That  is  because  in  deviations  the 
change  of  the  uterus  does  not  affect  the  absolute  position  of  the  organ, 
not  being  a  real  displacement ;  the  suspensory  ring  is  not  displaced. 
"VTe  must,  however,  admit  that  it  is  frequently  otherwise,  in  which 
case  descent  or  ascent  are  combined  with  deviation.  TVhen  the  uterus 
is  retroverted  it  is  almost  always  at  the  same  time  prolapsed;  when 
anteverted  it  is  often  elevated.  Sometimes  also  the  tissue  of  the  uterus 
is  altered  as  well  as  the  ligaments,  and  retroversion  is  accompanied  by 
retroflexion  and  prolapsus,  and  in  the  same  way  anteversion  is  accom- 
panied by  anteflexion  and  elevation.  Flexions  of  the  uterus  may, 
therefore,  coincide  with  deviations,  but  Marion  Sims  goes  too  far  iu 
regarding  them  as  different  degrees  of  the  same  condition.  The 
pathological  alteration  of  the  ligaments  is  the  real  cause  of  persis- 
tent deviations ;  the  pathological  alteration  of  the  tissue  of  the  uterus 
is  the  sole  cause  of  flexions.  With  regard  to  the  latter,  I  will 
try  to  explain  why  in  certain  circumstances  they  should  occur  simulta- 
neously. 

There  are  four  principal  deviations :  anteversion,  retroversion,  and 
lateral  versions,  right  and  left.  It  is  evident'  that  between  these 
cardinal  directions  there  may  be  intermediate  deviations,  designated  by 


DEVIATIONS 


389 


the  names  of  ante-later oversion  or  retro-lateroversion.     They  are^  how- 
ever, of  secondary  importance.     Anteversion  and  retroversion  are  much 


P'iG.  264. — Right  unicorn  uterus,  with  absence  of  the  horn  and  the  left  appen- 
dages, simulating  a  dexti'oversion  or  dextroflexion.  u,  uterus  ;  c  u,  cervix 
uteri ;  o,  ovary  ;  t.  Fallopian  tube. 

the  most  common  and  the  most  marked.  Lateroversions  are  limited 
by  the  broad  ligament,  in  which  the  organ  is  too  deeply  inserted  to 
be  able  to  deviate  considerably  in  either  direction.  A  great  many 
mistakes  have  been  made  with  regard  to  lateroversions  owing  to  the 
difficulty  of  diagnosis. 

Anteversion  and  retroversion  are  the  names  given  to  inclinations 
forwards  or  backwards  beyond  certain  limits.  When  once  produced 
they  may  be  carried  a  great  length,  especially  retroversion.  If  the 
fundus  is  inclined  forwards  or  backwards  twenty-five  or  thirty  degrees 
it  is  not  in  a  bad  position^  but  if  it  goes  to  forty  degrees  without  soon 
returning  to  its  normal  position  the  deviation  is  naturally  increased 
till  it  becomes  persistent.  At  forty-five  degrees  its  anterior  or  posterior 
surface  is  exposed  to  pressure  from  the  viscera,  and  consequently  it 
will  become  increasingly  deviated.  Anteversion  is  necessarily  arrested 
at  ninety  degrees,  the  uterus  then  resting  on  the  anterior  wall  of  the 
vagina  and  bladder.  Retroversion  encountering  no  obstacles  may 
reach  135  degrees,^  when  the  symptoms  become  more  marked,  such  as 
dragging  at  the  umbilicus  and  groins,  sacral  pain,  weight  at  the  anus, 
nausea,  dyspepsia,  &c.;  reduction  at  the  same  time  becomes  more 
difficult,  owing  to  the  uterus  becoming  enclosed  by  the  surrounding 
organs. 

'    Sims,  n]i.  cit.,  p.  2o6. 


390 


UTEEINE    DISEASES    IN    DETAIL 


Anteversion^  is  very  common.  It  is  only  au  exaggeration  of  the 
normal  inclination  of  the  uterus  during  foetal  life  and  during  preg- 
nancy. At  an  early  period  of  gestation  the  inclination  forwards  and 
to  the  right  becomes  more  marked,  and  sometimes  exceeds  the  normal 
limits,  necessitating  the  use  of  an  external  support.  It  is  very 
common  in  the  virgin  and  nullipara.  A  persistence  of  the  foetal  con- 
dition is  enough  to  produce  it,  or  this  state  may  be  aggravated  by 
dysmenorrhoea  or  by  the  increased  weight  of  the  fundus  of  the  organ, 
or  by  a  cicatricial  contraction  following  inflammation  of  Douglas's 
ligaments,  which  gives  an  essentially  patJiological  character  to  ante- 
version.  It  may  also  be  due  to  abnormal  development  of  the  anterior 
wall,  to  the  presence  of  a  fibroid  in  this  wall,  provided  that  the  tumour 


Fig.  265. — Anteversion  in  the  first  montii  of  pregnancy  :  m,  uterus;  c,  vagina, 
vulval  orifice  ;  it,  meatus  ;  v,  bladder,  compressed  by  the  body  of  the 
uteras  :  E,  rectum  ;  P,  pubis. 

has  its  seat  in  the  body  (for  if  it  is  developed  in  the  cervix  it  may,  on 
the  contrary,  produce  retroversion).  Nevertheless,  I  do  not  agree 
with  West,  that  it  is  chiefly  the  weight  of  the  organ  which  determines 
anteversion ;  the  iitero-sacral  ligaments  must  be  shortened.  The  fundus 
of  the  organ  compresses  and  pushes  the  bladder  before  it  and  rests 
against  the  pubic  symphysis,  sometimes  even  lying  behind  it.  The 
neck,  on  the  contrary,  rises  behind  into  the  concavity  of  the  sacrum, 
pushing  back  the  posterior  wall  of  the  vagina  and  the  anterior  surface 

'  Anteversion  attracted   attention  before  retroversion  ;  it  was  described  ex- 
actly by  Levret. 


DEVIATIONS 


391 


of  the  rectum,  which  it  depresses  so  as  to  hollow  out  a  kind  of  resting 
place  for  itself.  The  uterus  may  be  kept  firmly  in  this  vicious  position 
by  the  shortening  of  the  supra-pubic  ligaments,  especially  of  the 
utero-sacral  ligaments  which,  by  raising  the  neck  behind,  make  the 
fundus  descend  in  front.  What  Schultze  has  said  of  anteflexion  may 
be  applied  to  anteversion,  leading  us  to  distinguish  natural  congenital 
anteversion  from  pathological  anteversion  caused  by  posterior  peri- 
metritis with  adhesions,  cicatricial  and  retractile  alterations  of 
Douglas's  ligaments,  and  necessarily  requiring  a  totally  different  treat- 
ment. 

Reiroversion  is  always  pathological.  It  is  more  uncommon  than 
anteversion,  because  contrary  to  the  normal  inclination  of  the  uterus ; 
it  is  also  more  serious.  It  is  common  in  the  multipara  and  in  the 
aged.  Eetroversion,  although  contrary  to  the  normal  inclination  of 
the  uterus,  is  very  easily  produced  in  certain  circumstances  ;  the  pos- 
terior wall  of  the  uterus  being  naturally  thicker  than  the  anterior,  all 
congestion  or  hypertrophy  of  this  wall  with  relaxation  of  the  sus- 
pensory  ligaments  disposes  the  womb  to  become  retroverted  ;  a  tumour 
or  any  increase  in  the  weight  of  the  fundus  or  posterior  wall  has  a 
great  influence,  the  form  of  the  pelvis,  the  cavity  of  the  sacrum,  the 
presence  of  Douglas's  peritoneal  cul-de-sac,  helping  the  displacement 


Fig.  266. — Retroversion  of  the  uterus. 

of  the  organ  in  this  direction.  It  may  occur  suddenly  as  the  result 
of  an  accident  or  violent  effort,  not  only  during  pregnancy  (as  occurs 
most  frequently)  but  also  during  a  state  of  vacuity  with  or  without 
hypertrophy  ;  generally  it  comes  slowly  owing  to  gradual  relaxation 
of  the  ligaments ;  it  may  date  from  a  delivery,  miscarriage,  or  me- 
trorrhagia, it  is  increased  at  every  menstrual  period  as  well  as  by  con- 
stipation and  the  accumulation  of  urine,  and  it  becomes  incurable  by 
the  formation  of  utero-intestinal  and  pelvic  adhesions,  succeeding 
attacks  of  circumscribed  peritonitis.  It  may  be  slight  or  well-marked 
but,  once  produced,  it  goes  on  increasing  ;  sometimes  the  fundus  rests 
on  the  sacro-vertebral  angle,  sometimes  it  falls  below  this  angle  into 


392  UTERINE    DISEASES    IN    DETAIL 

the  concavity  of  the  sacrum,,  and  so  low  that  it  rests  not  only  on  this 
bone  but  on  the  perinseum  below  Douglas's  folds,  exercising  so 
much  pressure  on  the  anterior  surface  of  the  rectum  that  a  serious 
obstacle  is  placed  in  the  way  of  the  evacuation  of  the  faeces  or  the 
entrance  of  an  enema.  The  cervix^  although  unable  to  rise  to- 
wards the  symphysis  of  the  pubis^  is  nevertheless,  owing  to  the 
extreme  declivity  of  the  fundus  and  the  elongation  of  the  liga- 
ments which  allows  it  to  get  further  and  further  away  from  its  points 
of  attachment  to  the  promontory,  sometimes  on  the  same  level  as  the 
fundus,  sometimes  higher  than  the  fundus  itself,  the  weight  of  which 
forces  the  cervix  to  swing  forwards  and  to  push  before  it  the  neck  or 
fundus  of  the  bladder;  the  supra- pubic  and  utero-sacral  ligaments 
must  be  considerably  relaxed,  softened  and  elongated  before  this 
deviation  can  occur,  therefore  it  usually  precedes  prolapsus.  The 
cervix,  though  it  appears  to  rise,  never  does  so  (except  in  gestation), 
but  the  whole  organ  descends  and  the  fundus  more  so  than  the  neck ; 
the  vesical  adhesions  persisting  alone,  seem  to  be  the  cause  of  the 
cervix  being  dragged  forwards  and  upwards ;  the  anterior  wall  of  the 
vagina  is  often  shortened  in  long-standing  retroversions  ;  it  has  even 
seemed  to  me  that  sometimes  a  congenital  shortness  has  not  been 
without  influence  in  the  production  of  retroversion.  The  weight  of 
the  fundus^  and  the  pressure  of  the  abdominal  viscera  suffice  to  pro- 
duce and  keep  up  this  deviation,  in  which  the  ligaments  play  a  passive 
part  (which  is  not  the  less  the  principal,  owing  to  the  absence  of  all 
support  for  the  organ  in  consequence  of  their  relaxation),  just  the 
contrary  to  anteversion,  in  which,  by  their  retraction,  they  take  quite 
an  active  part.  Lastly,  hypertrophy  of  the  lowest  part  of  the  uterus 
is  often  observed  as  a  consequence  of  retroversion ;  in  anteversion 
we  have  seen  it  play  the  part  of  cause.  Pregnancy  is  a  serious  compli- 
cation requiring  prompt  reduction. 

Later  aversions  of  extreme  degree  are  rare,  though  slight  cases  are 
common  enough,  especially  to  the  right.  The  fundus  may  incline  to 
either  side  so  far  that  the  corresponding  angle  may  touch  the  pelvic 
wall,  whilst  the  neck,  rising  on  the  opposite  side,  touches  the  corres- 
ponding surface  of  the  cavity.  According  to  Aran^  the  broad  liga- 
ment corresponding  to  the  inclination  is  frequently  shortened,  the 
utero-sacral  ligament  of  the  same  side  atrophied  or  relaxed,  the 
utero-sacral  of  the  opposite  side  stretched  and  shortened ;  of  the  two 
supra-pubic  ligaments  the  one  corresponding  to  the  inclination  is  re- 
laxed or  shortened ;  the  other  is  stretched  or  elongated.  Some 
autopsies  have  enabled  me  to  verify  the  reality  of  these  alterations. 

Diagnosis. — When  we  find  that  a  considerable  number  of  devia- 
tions date  from  intra-uterine  life,  and  therefore  ought  to  be  all  the 
more  easily  supported  -,  that  the  uterine  cavities  present  neither  devia- 

'  The  development  of  a  tumour  in  the  posterior  wall  of  the  body  of  the 
organ  may  produce  retroversion,  whilst  its  development  in  the  cervix  behind 
may  produce  real  anteversion  by  pushing  the  body  forwards,  according  to 
nMario  Sims,  phenomena  which  are  the  reverse  of  those  I  have  indicated  for 
anteversion. 

2  Op.  cit.,  p.  1022. 


DEVIATIONS  393 

tion  nor  compression ;  lastly,  that  when  they  are  produced  in  a  wide 
pelvis  and  consequently  cause  no  functional  disturbance  in  neighbouring 
organs,  they  may  continue  for  a  long  time  without  giving  any  sign  of 
existence  ;  we  need  not  be  surprised  that  after  having  attached  too  much 
importance  to  versions,  a  reaction  has  set  in  tending  to  ignore  this  part 
of  uterine  pathology  too  completely. 

But  whilst  causing  little  pain  by  themselves  in  some  circumstances, 
versions  are  still  very  painful  affections  to  delicate  women  owing  to 
the  reaction  exercised  on  neighbouring  organs  when,  for  example, 
they  disturb  the  pathological  evolution  of  some  degeneration  of  the 
tissue,  of  inflammation  of  the  peritoneum,  of  the  broad  ligaments,  &c. 
It  is  the  contrary  with  prolapsus  and  flexions  (especially  retroflexion), 
which  are  painful  in  themselves.  This  is  easily  recognised  when  we 
have  to  do  with  a  compound  deviation,  especially  with  retroflexion 
combined  with  retroversion  and  prolapsus,  the  most  frequent  perhaps 
and  the  most  painful ;  when  the  retroflexion  and  prolapsus  are  cured,  the 
pain  is  alleviated,  and  although  a  considerable  amount  of  retroversion 
and  prolapsus  may  continue  the  patients  no  longer  complain  of  pain. 

Therefore  when  serious  symptoms  are  produced  by  deviations  the 
deviations  must  not  only  be  very  marked,  but  must  occur  in  excep- 
tional conditions,  in  impressionable  women,  or  in  a  narrow  pelvis,  or 
on  a  tumefied  uterus  surrounded  by  diseased  organs.  There  must  also 
be  uterine  or  peri-uterine  inflammation,  congestion,  hypertrophic  in- 
duration, or  some  other  morbid  alteration  of  the  uterus,  its  appendages, 
its  ligaments,  its  peritoneal  covering,  or  of  neighbouring  organs.  I 
do  not  mean  that  in  such  cases  the  deviation  plays  no  part.  On  the 
contrary,  I  think  that  it  contributes  to  increase  the  symptoms  and  to 
keep  up  the  morbid  state  which  is  alternately  cause  and  effect,  a  very 
important  consideration  both  with  regard  to  diagnosis  and  treatment. 
I  believe  that  deviation  (supposing  that  it  did  not  exist  from  the 
beginning)  when  once  produced  is  frequently  accompanied  by  uterine 
sufl'ering  which  did  not  exist  before,  especially  when  carried  to  such 
an  extent  that  the  relations  of  neighbourhood  are  completely  altered, 
and  that  the  neighbouring  organs  cannot  come  into  contact  in  these 
new  relations  without  giving  pain.  I  have  often  seen  the  pain  dis- 
appear as  if  by  enchantment  after  reduction.  I  presume,  therefore, 
that  in  the  majority  of  cases  the  symptoms  are  due  at  once  to  excessive 
displacement  and  to  some  complication.  I  presume  that  an  ordinary 
deviation  occurring  gradually,  as  frequently  happens,  and  free  from 
complication,  does  not  usually  determine  any  serious  functional  dis- 
turbance. Lastly,  I  am  certain  that,  when  carrifid  to  the  highest 
degree,  it  is  betrayed  by  pathognomonic  signs  (which  are  still  more 
marked  in  cases  of  flexion)  which,  apart  from  direct  examination, 
enable  us  to  diagnose  the  direction  and  the  degree  of  the  version.  This 
remark  is  especially  applicable  to  retroversion. 

Subjective  signs. — The  common  symptoms  are  general  symptoms, 
especially  disorders  of  digestion,  innervation  and  nutrition,  which  are 
common  to  a  great  many  uterine  maladies,  and  local  symptoms,  such 
as  a  feeling  of  weighf,  of  dull  \)n\n  or  dragging  in  the  pelvis,  in  the 


394  UTEEINE    DISEASES    IN    DETAIL 

loinSj  in  the  abdomen^  groins  and  perinseum,  increased  by  standing, 
walking,  fatigue,  constipation,  retention  of  urine,  &c.  The  local 
symptoms  appear  to  depend  less  on  the  sensitiveness  of  the  uterus  or 
on  the  action  exercised  by  this  deviated  organ  on  its  ligaments,  than 
on  the  pressure  or  painful  traction  which  the  abnormal  position  of  the 
womb  and  the  change  of  its  relations  exercise  on  the  neighbouring 
organs,  especially  on  the  bladder  and  rectum.  Disorders  of  the  urinary 
excretion  and  of  defecation  are  the  most  common  of  all  the  probable 
symptoms  of  uterine  deviation.  Sterility  and  the  existence  of  more  or 
less  persistent  uterine  leucorrhoea  may  also  be  placed  among  the 
number  of  the  symptoms  which  are  produced  in  cases  of  deviation,  but 
which  cannot  be  taken  as  proof  of  their  existence  rather  than  of  that 
of  any  other  morbid  state. 

As  for  the  special  symptoms  distinctive  of  the  various  kinds  of  devia- 
tion, it  is  impossible  to  say  that  retention  or  incontinence  of  urine  is 
specially  connected  with  anteversion  and  constipation  with  retro- 
version. 1  have  never  observed  anything  especially  distinctive  with 
regard  to  this :  frequent  desire  for  micturition,  owing  to  the  pressure 
which  the  weight  of  the  uterus  exercises  on  the  bladder,  is  certainly  a 
symptom  of  anteversion;  difficulty  in  micturition  and  tenesmus,  in 
consequence  of  compression  of  the  uterine  cervix  against  the  neck  of 
the  bladder  and  the  urethra,  are  also  sure  signs  of  retroversion. 
Nevertheless,  as  the  uterus  frequently  preserves  its  obhquity  (fundus 
to  the  right)  in  retroversion,  the  urethra  escapes  the  pressure  exercised 
on  it  by  the  cervix  being  forced  against  the  pubis.  What  is  more 
certain  is  that,  in  the  majority  of  patients,  the  symptoms  which  appear 
to  be  due  to  anteversion  are  alleviated  by  the  dorsal  decubitus,  whilst 
in  patients  suffering  from  retroversion  the  dorsal  decubitus  even  in  the 
best  conditions,  with  a  perfectly  horizontal  posture,  flexion  of  the 
limbs  and  general  relaxation  of  the  muscles,  is  usually  powerless  to 
dissipate  pain.  In  some  patients  even  the  pain  is  increased  by  this 
posture,  so  much  so  as  to  oblige  them  to  turn  on  one  side,  and  finally 
on  the  abdomen.  Another  symptom  which  I  have  observed  in  retro- 
version is  a  sensation  of  dragging  at  the  umbilicus,  extending  from 
this  point  to  the  pelvis,  and  aggravated  by  the  dorsal  decubitus.  In 
retroversion  the  pressure  exercised  on  the  hypogastrium  (when  the 
patient  is  standing)  from  below  upwards  and  from  before  backwards, 
either  temporarily  by  the  hand  or  in  a  permanent  manner  by  a  hypo- 
gastric belt,  excites  pain  in  place  of  alleviating  it ;  the  contrary  occurs 
in  anteversion.  Lastly,  in  retroversion  sterility  is  much  more  common 
than  in  anteversion,  owing  to  the  mechanical  difficulty  placed  in  the 
way  of  the  entrance  of  the  semen. 

In  lateral  versions  I  have  observed  nervous  symptoms,  neuralgic 
darting  pains  in  the  limbs,  seemingly  dependent  on  compression  of  the 
nerves  coming  from  the  pelvis,  on  the  side  towards  which  the  organ 
inclines.  I  have  merely  mentioned  what  I  have  observed,  leaving  it  to 
future  observers  to  clear  up  what  is  obscure  in  the  matter.  The  co- 
existence of  a  morbid  condition  complicating  a  deviation  has  been  till 
now  a  great  obstacle  in  the  way  of  determining  the  special  character- 


DEVIATIONS  395 

istics  of  each;  but  a  strict  analysis  of  facts  has  put  us  on  the  right 
track,  as  will  be  seen  still  naore  clearly  when  we  come  to  consider 
flexions. 

Objective  signs. — If  it  is  difficult  to  judge  of  the  existence  and 
direction  of  a  deviation  from  the  symptoms  experienced  by  the  patient, 
it  is  on  the  contrary  very  easy  to  determine  it  by  direct  exploration. 
Tlie  association  of  palpation  with  vaginal  and  rectal  touch,  the  use  of 
the  sound  (except  in  cases  of  pregnancy),  the  catheter,  and  the  specu- 
lum, leave  us  in  no  doubt  as  to  the  existence  and  direction  of  a 
uterine  version.  It  must  not,  however,  be  forgotten  that  in  Levret^s 
case  the  anteverted  fundus  was  taken  for  a  stone,  and  that  the  patient 
died  from  the  consequences  of  lithotomy  performed  owing  to  the 
mistaken  diagnosis ;  a  slight  engorgement  of  the  anterior  wall  of 
the  uterus  and  an  unusual  shortness  of  the  round  ligaments  (pro- 
bably also  of  the  utero-sacral  ligaments)  were  the  only  appreciable 
causes  of  this  displacement. 

In  anteversion  the  cervix  can  only  be  felt  by  digital  touch  in  the 
concavity  of  the  sacrum  where  it  is  often  difficult  to  catch  the  os  which 
looks  straight  backwards.  When  the  finger  can  bring  the  cervix 
forward  the  displacement  of  the  fundus  in  the  contrary  direction  is 
easily  perceived ;  catheterism  associated  with  hypogastric  palpation 
renders  the  direction  of  the  displacement  and  the  temporary  replace- 
ment of  the  organ  still  more  evident.  Eectal  touch  determines  the 
degree  of  compression  exercised  on  the  rectum  by  the  neck,  and  dis- 
closes the  absence  of  the  rest  of  the  organ  above  this  inferior  segment ; 
it  shows  that  the  shortened  utero-sacral  ligaments  are  stretched  when 
we  try  to  replace  the  uterus;  above  all,  it  decides  the  question 
whether  there  is  any  tumour  behind  the  uterus  either  belonging  to 
that  organ  or  foreign  to  it  by  which  the  deviation  is  caused.  The 
speculum  only  allows  the  anterior  lip  to  be  seen  ;  in  order  to  bring 
the  whole  organ  into  view  the  cervix  must  be  caught  by  tenaculum 
hook  forceps  or  a  sound  and  drawn  forwards  whilst  the  speculum  is 
inclined  backwards,  the  buttocks  of  the  patient  being  raised,  or  her 
lower  limbs  flexed  as  far  as  possible.  In  using  the  sound  the  handle 
must  be  considerably  lowered  so  as  to  depress  the  fourchette,  whilst 
the  hypogastrium  must  be  compressed  in  order  to  raise  the  fundus  ; 
the  buttocks  of  the  patient  must  project  over  the  edge  of  the  bed 
or  the  instrument  will  not  enter  the  cavity  of  the  womb  ;  then  the 
replacement  of  the  organ  should  be  attempted  gently,  with  a  view  to 
revealing  the  presence  or  absence  of  adhesions,  the  degree  of  retrac- 
tion of  the  utero-sacral  ligaments  and  the  possibility  of  a  return  to 
the  normal  direction. 

In  retroversion,  after  having  vainly  tried  to  discover  the  cervix  in 
the  posterior  vaginal  cul-de-sac  which  often  presents  a  bulging  in 
the  form  of  a  smooth  and  rounded  tumour  owing  to  the  presence  of  the 
retroverted  fundus,  we  at  last  find  it  against  the  anterior  wall  and 
discover  the  os  behind  the  pubic  symphysis.  In  bringing  it  down  the 
finger  experiences  the  sensation  of  the  gradual  replacement  of  the 
fundus.     This  sensation  becomes  more  evident,  and  replacement  easier 


396  UTERINE    DISEASES    IN    DETAIL 

if  rectal  is  combined  with  vaginal  touch.  When  this  replacement  is 
effected,  the  association  of  abdominal  palpation  with  vaginal  and 
rectal  touch  reveals  in  the  hypogastrium  the  presence  of  the  fundus 
which  before  was  absent.  Various  circumstances  may  have  increased 
the  size  of  the  uterus,  especially  gestation  which  may  render  replace- 
ment painful  and  difficult.  Examination  of  the  cervix  by  speculum 
often  becomes  even  more  difficult  than  in  anteversion ;  in  order  to 
bring  the  diseased  organ  into  view  and  apply  remedies  to  it,  I  have 
sometimes  been  obliged  to  place  the  patient  in  pronation  on  her  elbows 
and  knees,  or  on  one  side,  or  in  a  standing  position  with  the  trunk 
flexed  on  the  thighs,  the  speculum  being  introduced  from  behind.  In 
using  the  sound  the  handle  of  the  instrument  must  be  raised  towards 
the  pubis,  whilst  a  finger  introduced  into  the  vagina  or  rectum  raises 
the  uterus  and  ascertains  the  absence  or  presence  of  adhesions  which 
may  retain  the  fundus  in  the  vagino-rectal  cul-de-sac. 

It  is  unnecessary  to  dwell  long  on  lateroversions,  except  to  say 
that  they  never  reach  the  same  degree  that  antero-posterior  deviations 
do,  and  that  other  causes  are  added  to  the  preceding  in  producing 
them,  viz.  the  relaxation  or  contraction  of  the  broad  and  round  liga- 
ments, alone  or  associated  with  relaxation  or  contraction  of  one  of  the 
utero-sacral  ligaments. 

When  the  uterus  resists  reduction,  it  is  important  to  diagnose  care- 
fully the  irred.ucibility  and  the  cause  of  the  irreducihility .  In  the  case 
of  anteversion,  if  the  fundus  of  the  uterus  is  fixed  anteriorly  by  adhe- 
sions, which  is  rare,  it  will  be  impossible  to  raise  the  organ  by  the  usual 
method,  which  consists  in  bringing  the  neck  into  the  anterior  vaginal 
cul-de-sac  behind  the  inner  surface  of  the  pubis  vv'ith  the  index  finger 
of  the  left  hand,  whilst  the  fundus  is  pushed  backwards  by  the  other 
hand  acting  on  the  hypogastrium  through  the  abdominal  wall ;  if  the 
neck  is  retained  posteriorly  by  the  shortened  sacro-uterine  ligaments, 
by  introducing  the  index  finger  into  the  rectum  or  even  by  directing 
it  towards  the  posterior  cul-de-sac  of  the  vagina  at  the  same  time  that 
the  cervix  is  depressed  by  means  of  the  tenaculum  hook,  the  sacro- 
uterine ligaments  will  be  felt  stiff  and  resisting  like  two  stretched 
guitar  strings.  In  the  case  of  retroversion  the  sound  must  necessarily 
be  resorted  to.  Sims^  prefers  his  articulated  one,  in  order  to  avoid 
injuring  the  fundus  in  raising  the  organ;  I  prefer  a  flexible  instrument 
the  curve  of  which  can  be  adapted  to  circumstances  ;  whilst  trying 
to  replace  the  uterus  with  this  instrument,  we  can,  by  means  of  rectal 
or  vaginal  touch  associated  with  external  palpation,  determine  the  ex- 
istence of  any  utero-peritoneal  adhesions  or  of  any  tumour  adherent 
to  the  uterus,  sessile,  pediculated  or  independent  of  this  organ.  We 
may  remark  that  the  means  of  examination  just  described  and  the 
analysis  of  the  symptoms  serve  not  only  to  prove  the  existence  of  a 
deviation  and  to  show  its  direction,  but  they  also  make  known  its 
condition,  whether  reducible  or  not,  and  the  co-existence  of  various 
concomitant  pathological  conditions,  and  whether  they  exist  as  cause, 
effect,  or  as  simple  complication.  The  importance  of  this  part  of  the 
'  Ainnfivican  Journal  of  Medical  Science,  Jan.  185.S. 


DEVIATIONS  397 

diagnosis  will  be  understood  if  we  consider  that  the  symptoms  observed 
in  cases  of  deviation  are  due  to  these  morbid  states  as  well  as  to  the 
deviation  itself,  and  that  there  is  a  possibility  of  rendering  the  deviation 
tolerable  by  first  curing  the  complication  ;  and  in  the  second  place,  if  we 
reflect  that,  whatever  be  the  sequence  of  the  pathological  phenomena, 
even  if  the  deviation  should  be  the  cause  of  several  of  the  phenomena, 
such  as  congestion,  engorgement,  hypertrophy  of  the  uterus,  &c.,  the 
deviation  is  always  the  result  of  some  cause,  whether  laxity  or  con- 
traction of  the  ligaments,  or  increased  weight  and  volume  of  the 
uterus,  or  unequal  relative  proportion  of  the  two  segments,  various 
pathological  conditions  of  the  organ,  functional  disorders  of  the 
neighbouring  organs,  peri-uterine  inflammation  and  its  conse- 
quences, or  tumours  of  the  appendages  or  pelvic  cavity.  All  the 
indications  which  serve  as  a  basis  for  the  treatment  of  uterine  devia- 
tion arise  from  a  well-made  analysis  of  these  various  elements  of  the 
question. 

Treatment. — There  are  few  uterine  diseases  which  resist  treatment 
more  than  deviations.  This  is  owing  to  the  difficulty  of  discovering 
the  true  causes,  and  still  more  of  finding  suitable  means  of  combating 
them  successfully. 

The  best  indications  are  those  drawn  from  the  nature  of  the  malady. 
Unfortunately  this  nature  has  been  very  little  known  till  lately.  This 
ignorance  of  the  indication  as  well  as  the  difficulty  of  resolving  it  un- 
fortunately led  the  last  medical  generation  to  form  a  hopeless  prognosis, 
which  may  be  summed  up  in  Velpeau's  words  :  *'  Versions  do  not  kill, 
but  they  are  never  cured."  In  fact  when  once  produced  they  have 
little  tendency  to  improve  ;  on  the  contrary,  they  almost  always  become 
worse,  and  exercise  a  more  and  more  marked  influence  on  the  general 
health,  which  is  gradually  disordered,  as  in  all  chronic  uterine  affec- 
tions. Till  lately  they  have  resisted  the  (apparently)  most  rational 
treatment,  condemning  women  to  a  miserable  life  owing  to  the  rest  to 
which  they  were  forced  to  submit,  and  the  necessity  of  using  all  their 
lives  means  of  retention  as  troublesome  as  insufficient.  During  the  last 
few  years,  however,  owing  to  a  more  exact  analysis,  the  true  causes  of 
deviations  have  been  discovered,  and  have  been  found  to  differ  in  each 
case,  so  that  there  is  now  reason  to  hope  that  a  curative  treatment 
may  be  instituted  for  each. 

i  have  observed  with  great  interest  that  several  physicians  have  fol- 
lowed me  in  the  path  of  analysis  which  has  led  me  to  discover  the  true 
cause  of  each  deviation  and  each  flexion,  or  they  may  have  set  out  in 
ignorance  of  my  investigations  arriving  at  an  analogous  result,  which 
is  the  best  confirmation  of  the  correctness  of  my  conclusions.  These 
conclusions,  of  which  I  gave  some  indications  in  the  first  edition  of  this 
work,  and  which  I  explained  clearly  in  the  second  edition  in  1871,  have 
since  been  developed  in  a  paper  on  retroflexion  read  before  the  IVench 
Association  for  the  Advancement  of  Science  in  1874.  In  Germany 
and  England  the  cause  of  flexions  and  versions  has  been  appreciated  in 
the  same  way  by  very  competent  men,  especially  by  Schultze  and 
Barnes.     I  can  therefore  confidently  present  tlie  results  at  wliich  I 


398  UTERINE    DISEASES    IN    DETAIL 

have  arrived,  and  will  here  state  them  in  so  far  as  they  relate  to 
versions. 

Anteversion,  so  long  as  the  mobility  of  the  organ  is  preserved,  is 
only  an  exaggeration  of  the  normal  direction  of  the  womb;  when  there 
is  immobility  owing  to  neo-membranous  adhesions  above  the  bladder 
or  exudations  and  retractile  cicatricial  tissue  in  Douglases  pouch,  or 
contraction  and  shortening  of  the  utero-sacral  ligaments,  it  is  patholo- 
gical and  requires  serious  treatment. 

Retroversion  is  always  abnormal  or  pathological ;  it  involves  a 
direction  of  the  organ  quite  contrary  to  its  normal  one,  and  may  reach 
a  degree  considerably  exceeding  the  greatest  degree  of  anteversion.  It 
is  also  due  to  the  elongation  of  Douglas's  ligaments,  although  other 
causes  may  incline  the  organ  in  this  direction.  We  must  therefore 
consider  how  these  ligaments  can  be  shortened. 

The  shortening  or  the  elongation  of  these  ligaments  may  be  associated 
with  the  shortening  or  elongation  of  the  broad  ligaments  or  some  other 
such  alteration  in  the  same  or  in  a  contrary  direction,  on  those  of  the 
same  or  a  different  side,  whence  a  mixed  inclination  accompanied  by 
torsion,  latero-position,  &c.  &c. 

1 .  Treatment  of  Versions  in  general 

The  indications  are  necessarily  grouped  under  three  heads,  according 
to  whether  they  are  addressed  to  the  cause  of  the  malady  (medical 
treatment),  or  only  to  its  effects  (mechanical  treatment),  for  which  the 
indication  may  be  either  reduction  or  the  maintenance  of  reduction 
when  once  it  has  been  effected. 

I.  General  and  local  medical  treatment  is  that  which  is  addressed 
to  the  cause. 

The  original  cause  of  the  deviation  possibly  being  in  the  uterus,  any 
increase  in  volume  or  in  the  weight  of  the  organ  will  be  treated,  accord- 
ing to  whether  its  nature  be  congestive,  hypertrophic  or  inflammatory, 
by  resolvents,  alteratives  or  antiphlogistics,  as  well  as  by  antidiathetics 
appropriate  to  the  affection  which  keeps  up  the  congestion.  If  the 
tumefaction  of  the  uterus  depends  on  pregnancy  it  will  be  treated 
simply  by  posture,  and  often  this  cannot  be  done  till  after  reduction, 
but  it  will  very  seldom  be  treated  by  abortion  or  evacuation  of  the 
uterine  cavity.  If  it  depends  on  the  presence  of  a  tumour,  it  may  in 
some  cases  be  treated  by  extirpation  of  the  tumour. — If  the  cause 
proceeds  from  an  alteration  in  the  means  of  suspension  it  will  be 
treated  by  resolvents,  tonics  and  all  general  and  local  means  suitable 
for  overcoming  sometimes  contraction  (for  anteversion),  sometimes 
elongation  of  the  ligaments  (for  retroversion),  such  as  restoratives, 
iron,  mineral  waters,  hydropathy,  electricity,  strychnia,  &c.  The 
same  means  may  be  employed  in  different  cases  or  in  complex  cases, 
for  they  may  be  applied  simultaneously  with  equal  effect  to  total  or 
partial  tumefaction  of  the  uterus  or  to  the  alteration  of  its  suspensory 
organs,  and  it  is  unnecessary  to  say  that  posture  may  favour  their 
action.     By  the  use  of  these  means  we  usually  succeed  in  obtaining  a 


DEVIATIONS  399 

tolerance  analogous  to  that  which  characterises  the  arrival  of  the  meno- 
pause which  puts  an  end  to  complications  and  reduces  the  version  to 
its  simple  state. 

II.  Reduction  is  directed  to  the  effect,  i.  e.  to  the  version.  It  may 
be  impossible  owing  to  adhesions  or  even  to  extreme  contraction  of  the 
ligaments,  as  in  certain  anteversions.  Even  then  we  must  not  give 
up  hope  of  triumphing  over  them  by  resolvents.  It  may  be  difficult, 
e.  g.  when  the  gravid  uterus  is  fixed  in  the  pelvis  in  a  state  of  retro- 
version :  in  this  case  the  difficulty  may  reach  impossibility,  therefore 
evacuation  of  the  bag  of  waters^  by  puncture  has  been  tried,  in  order 
to  make  reduction  possible.  Supposing  reduction  is  possible,  how 
should  it  be  performed  when  the  uterus  is  empty  and  when  it  is  full  ? 
When  it  is  empty  the  hand,  the  sound  or  other  instruments  may  be 
used.  When  it  is  full  it  is  sometimes  indispensable,  after  employing 
the  instruments  or  manoeuvres  of  reduction,  to  subject  the  patient  to 
certain  preliminary  operations,  catheterism,  or  vesical  or  uterine  punc- 
ture, &c.  In  all  cases  and  before  any  reduction  care  must  be  taken  to 
empty  the  bladder  and  rectum. 

Reduction  requires  that  the  patient  should  be  placed  in  a  special 
posture,  varying  according  to  the  direction  of  the  inclination.  In 
reducing  anteversion  the  most  favorable  position  is  the  dorsal  decu- 
bitus with  forced  flexion  of  the  lower  limbs  and  elevation  of  the  pelvis. 
In  retroversion  it  is  the  genu-pectoral  posture. — The  manoeuvres 
of  reduction  are  performed  by  the  introduction  of  one  or  more 
fingers  or  of  the  whole  hand  into  the  vagina,  combined  with  hypo- 
gastric palpation  and  pressure;  in  a  w^ord,  by  bimanual  palpation. 
In  rare  cases,  where  the  hand  does  not  suffice  to  reach  and  push 
back  the  uterus  through  the  vaginal  walls,  some  simple  instru- 
ment that  could  not  hurt  the  vaginal  mucous  membrane  can  be  used. 
Marion  Sims  uses  sponge-holders  furnished  with  sponges,  one  of  which, 
resting  in  the  posterior  cul-de-sac  of  the  vagina,  raises  the  fundus  of 
the  uterus  in  retroversion,  whilst  the  other,  resting  afterwards  on  the 
anterior  lip  of  the  cervix,  assists  the  action  of  the  other  and  completes 
the  reduction ;  the  latter  may  be  replaced  by  a  tenaculum  hook  fas- 
tened into  the  cervix  and  drawing  it  backwards.  If  the  introduction 
of  the  hand  into  the  vagina  does  not  suffice  we  must  try  to  effect  re- 
placement of  the  uterus  by  the  rectum,  introducing  one  or  more  fingers, 
or  the  whole  hand  as  Dusaussoy  did,  or  an  empty  bladder,  which  is 
distended  with  air  when  in  place,  or  a  wooden  instrument,  &c.  These 
vaginal  or  rectal  manipulations  may  be  aided  not  only  by  pressure  on 
the  hypogastrium,  but  also  by  raising  the  uterus  by  means  of  a  sound 
introduced  into  the  bladder.  Lastly,  in  a  state  of  vacuity,  the 
sound  should  be  used  after  the  other  means  to  eS'ect  reduction.  In 
every  case  it  is  the  best  means  of  determining  whether  reduction  is 
possible  or  whether  it  is  hindered  by  utero-peritoneal  adhesions  or 
extreme  contraction  of  the  ligaments ;  but  the  possibility  of  these 
serious  complications  must  never  be  lost  sight  of,  the  sound  being 

'  Wm.  Hunter,  Med.  Ohs.  and  Inquiries,  iv,  40G. — Cliurcliill,  op.  cit.,  p. 
428.  Dublin,  1864. 


400  UTEEINE    DISEASES    IN    DET2VIL 

used  with  great  care,  so  as  to  prevent  the  effects  of  a  dangerous  trau- 
matism in  the  case  of  these  obstacles  existing. 

III.  Retention  is  easy  in  pregnancy^  i.  e.  when  reduction  itself  has 
been  difficulty  as  occurs  in  cases  of  hernia  or  luxation  necessitating 
replacement  of  the  organs  in  their  natural  relations.  In  proportion  as 
the  foetus  is  developed  and  the  uterus  rises  it  becomes  less  and  less 
possible  for  this  organ  to  enter  the  pelvic  cavity,  and  consequently 
for  the  deviation  to  be  reproduced. — In  all  other  cases,  on  the  con- 
trary, retention  is  very  difficult.  Therefore  it  is  necessary  to  repeat 
the  manoeuvres  of  reduction  from  time  to  time,  so  that  the  advantages 
of  the  instruments  of  retention  may  not  be  lost.  The  idea  has  been 
entertained  of  making  use  of  the  instrnments  of  reduction  for  reten- 
tion strictly  so  called.  Such  was  the  origin  of  the  methods  so  much 
talked  of  a  few  years  ago,  and  which,  like  so  many  others,  have  been 
alternately  too  much  praised  and  too  much  decried. 

1.  Uterine  pessaries. — The  simplest  of  these  instruments  is  Simp- 
son's stem  pessary,  the  ball  of  which  by  filling  the  uterine  extremity  of 
the  vagina  suffices  to  keep  the  instrument  in  place  and  the  uterus 
reduced.^  I  think  it  should  be  used  as  little  as  possible,  its  applica- 
tion being  reserved  for  flexions,  and  care  being  taken  not  to  leave  it 
in  the  uterus  for  more  than  a  few  hours.  In  the  following  chapter  I 
will  indicate  the  best  way  of  making  short  and  repeated  applications  of 
the  galvanic  director  and  the  advantages  to  be  obtained  from  it. 

2.  Vaginal  pessaries. — The  dangers  inherent  in  the  use  of  intra- 
uterine pessaries  have  led  to  their  being  almost  completely  abandoned  for 
vaginal  pessaries.  Globular  pessaries  have  been  tried,  care  being  taken 
to  apply  them  in  the  anterior  vaginal  sinus  in  cases  of  anteversion,^  in 
the  posterior  pouch  or  in  the  rectum  in  cases  of  retroversion,  so  as  to 
take  up  the  place  which  the  body  of  the  organ  would  occupy  in  leaning 
forwards  or  backwards,  and  consequently  to  prevent  the  return  of  this 
inclination.  This  mode  of  retention,  however,  can  only  be  eflfectual 
when  there  is  a  considerable  and  painful  distension  of  the  vagina.  A 
good  plug  of  cotton  saturated  with  glycerine  or  charged  with  tannin 
may  render  great  service  if  placed  behind  the  cervix  in  anteversion,  and 
before  it  in  retroversion;  in  the  latter  case  its  action  will  be  assisted  if 
the  perinseum  is  raised  by  means  of  a  good  perinseal  pad.  The  ineffi- 
ciency of  the  globular  pessaries  has  led  to  their  form  being  modified  so 
as  to  make  them  bulge  more  at  the  side,  where  they  have  to  exercise 
pressure  on  a  higher  level  in  the  vaginal  cul-de-sac  to  prevent  the 
fundus  from  falling  back  into  it.  Even  this,  however,  is  insufficient. 
Hence  Hervez  de  Chegoin's  idea  of  the  shovel  pessary  (see  Pig,  172, 
p.    197),    intended   both   to   maintain   the    position   of    the   cervix 

^  Valleix,  ty  giving  more  fixity  to  the  instrument,  by  the  form  and  adjust- 
ment o£  his  plate  and  by  the  supporting  bandage  which  he  added,  spoiled  in 
place  of  improving  it ;  and  the  fatal  results  due  to  its  use  are  to  be  attributed 
to  this  absolute  immobility  which  he  gave  it. 

2  Steiger  succeeded  in  curing  an  anteversion  causing  sterility,  of  many  yeare 
standing,  in  two  months,  by  advising  the  patient  to  retain  her  urine  as  long  as 
possible.  The  distended  bladder  in  this  case  acted  better  than  the  best  pessary 
would  have  done. 


DEVIATIONS  401 

and  to  straighten  the  fundus;  Kennedj''s  pessary  was  of  the  same 
kind.  These  pessaries  suppose  the  integrity  and  resistance  of  the 
perinseum  which  forms  their  basis  of  support.  In  the  numerous  cases 
in  which  this  support  is  wanting  it  must  be  replaced  by  a  T  bandage, 
or  else  elastic  pessaries  of  the  same  shape  must  be  substituted.  They 
may  also  be  replaced  by  the  pessary  of  Simpson  and  Priestley  {see 
Fig.  173,  p.  197),  or  better  still,  by  Hodge's  sigmoid  parallelogram 
(see  Fig.  l75,  p.  197)  in  aluminium.  In  treating  of  prolapsus  I 
described  its  mode  of  action  and  the  way  in  which  it  should  be  intro- 
duced (Fig.  260).  It  is  equally  useful  in  the  treatment  of  retro- 
version, though  it  cannot  be  trusted  to  absolutely ;  whilst  its  insuf- 
ficiency for  anteversion  is  evident.  A  lever  pessary  should  be  modelled 
in  tin  mixed  with  a  little  lead  to  the  size  and  form  of  the  vagina  of 
each  patient.  When  properly  adjusted  this  malleable  model  is  sent 
to  an  instrument  maker,  who  makes  a  replica  in  silver  or  aluminium. 
This  pessary  often  alleviates  pain  in  retroversion,  and  it  rectifies  the 
position  of  the  organ  sufficiently  to  facilitate  conception  by  the  mechan- 
ism explained  when  treating  of  prolapsus  (p.  379).  I  have  modified 
Hodge's  pessary,  making  it  suitable  for  retroversion  and  retroflexion, 
by  adding  to  it  a  cervical  arch,  which  keeps  the  cervix  back,  preventing 
it  from  coming  forwards  again,  and  which  consequently  prevents  the 
fundus  from  falling  back.  At  the  union  of  the  cervical  arch  with 
Hodge's  lever  two  pieces  of  whalebone  allow  the  two  parts  of  the 
instrument  to  approach  each  other  in  order  to  facilitate  its  intro- 
duction by  the  vulva. 

3.  Means  of  retention  to  he  applied  in  the  neighbourhood  of  the 
uterus. — The  use  of  large  tampons  in  the  rectum  has  been  pro- 
posed by  Huguier^  in  the  treatment  of  retroversion  and  retroflexion. 
But  for  such  high  authority  I  should  have  thought  such  a  means 
impossible,  on  account  of  the  pain  and  tenesmus  that  it  would  pro- 
voke, not  to  speak  of  the  repugnance  it  inspires.  The  hypogastric  belt 
(Fig.  148)  is  useful  during  pregnancy  in  supporting  the  uterus  when  in- 
clined more  or  less  forwards.  In  a  state  of  vacuity  it  is  also  frequently 
useful,  because  it  supports  the  abdominal  viscera  and  prevents  their 
weight  from  pressing  painfully  on  the  uterus,  especially  in  the  case  of 
anteversion.  In  the  case  of  retroversion  I  am  convinced  that  the  use  of 
the  hypogastric  belt  increases  the  pain,  owing  to  the  propulsion  of  the 
viscera  towards  the  vertebral  column,  which,  combined  with  the  weight 
of  these  organs,  produces  a  resultant  directed  into  the  cavity,  i.  e. 
against  the  retroverted  uterus.  The  uterus  probably  then  supports  a 
more  considerable  pressure  than  when  a  portion  of  the  visceral  pressure 
is  not  pushed  back  by  the  belt,  but  is  freely  exercised  on  the  hypo- 
gastrium.  This  explanation  seems  to  me  all  the  more  likely  as 
patients  affected  with  retroversion  always  complain  of  the  use  of  a 
hypogastric  belt,  and  I  have  relieved  a  great  many  by  simply  making 
them  lay  it  aside.  Many  physicians  are  in  the  habit  of  prescribing  it 
for  every  deviation,  with  the  mistaken  idea  of  immobilising  the  uterus 
and  viscera  without  considering  the  real  eff'ect  that  it  produces. 
I  Be  Vhysterometrie,  p.  337.  Paris,  1865. 

26 


402  UTERINE    DISEASES    IN   DETAIL 

Thus,  on  the  one  hand  the  hypogastric  belt,  alone  or  aided  by  the 
perinseal  pad  [see  Pigs.  150,  151,  152,  p.  192),  on  the  other  hand  the 
perinseal  pad  associated  with  the  use  of  a  Hodge's  lever  pessary  in  the 
vagina,  or  better  still  my  modification  of  it,  are  more  generally  effectual, 
the  former  in  anteversion,  the  latter  in  retroversion,  I  have  sometimes 
used  them  with  great  advantage  for  patients  who  could  not  walk  with- 
out them.  In  applying  them  I  have  never  thought  of  immobilising 
the  uterus,  but  only  of  maintaining,  by  the  equal  pressure  in  aU  direc- 
tions which  this  organ  then  receives,  the  rectitude  of  its  position  or 
at  least  its  stability  sufficiently  to  prevent  its  exercising  pressure  or 
causing  dragging  pains  or  undergoing  the  same  from  neighbouring 
organs ;  in  short,  from  experiencing  or  provoking  pain.  _ 

4.  Operations  for  retention. — Lastly,  cauterisation  maybe  employed 
as  a  natural  means  of  retention  which  may  become  curative.  It  may 
be  applied  in  two  ways  :  as  a  resolvent  of  an  engorgement  or  chronic 
hypertrophic  congestion,  or  as  a  means  of  replacing  the  uterus  in  position 
by  the  retractility  of  the  cicatricial  tissue  which  foUows  the  suppuration 
produced  by  burning.  The  former  mode,  by  diminishing  the  tume- 
faction and  weight  of  the  organ,  diminishes  also  its  tendency  to  incline 
towards  the  side  on  which  its  centre  of  gravity  is  deprived  of  support 
or  suspension.  In  such  a  case  cauterisation  ought  to  be  applied  largely 
to  the  cervix  or  deeply  to  its  tissue  by  ignipuncture  applied  to  several 
points  of  the  most  tumefied  portion ;  it  may  be  destructive  if  the 
latter  is  much  swollen  ;  in  any  case  it  acts  as  an  alterative,  bringing 
into  play  a  work  of  absorption  and  resolution  under  the  influence 
of  which  the  size  of  the  organ  may  diminish  in  a  few  weeks  and 
especially  in  a  few  months  in  a  notable  manner,  especially  when  this 
action  is  seconded  by  hydropathy  and  resolvent  medication.  The 
second  mode,  that  oi  replacing  tke  organ, -which  1  have  employed  for  a 
long  time  after  the  example  of  Amussat^,  aims  at  forming  a  cicatricial 
band,  extending  from  the  neck  to  one  of  the  vaginal  walls  and  occu- 
pying the  utero- vaginal  sinus  which  corresponds  to  the  inchnation. 
That  is  to  say  when  there  is  anteversion  the  caustic  must  be  applied 
in  the  anterior  sinus,  so  that  the  cicatricial  band  in  contracting  may 
bring  the  cervix  near  to  the  anterior  wall  of  the  vagina,  and  by 
making  the  whole  organ  swing  in  its  suspensory  ring,  separate  its 
fundus  from  the  bladder  and  raise  it  in  the  cavity ;  in  cases  where  the 
anteversion  was  not  pathological  I  have  had  some  success  from  the 
use  of  this  means.  When  on  the  contrary  there  is  retroversion,  the 
caustic  or  fire  must  be  applied  in  the  posterior  sinus,  so  that  the 
cicatrix  in  retracting  brings  the  cervix  near  to  the  posterior  wall  of 
the  vagina,  and  removes  the  fundus  from  the  rectum;  but  it  is 
dangerous  to  use  this  means  in  a  case  of  retroversion  on  account  of 
the  peritoneum  being  so  near.  The  suture  of  a  transverse  fold  of 
the  vagina  may  be  resorted  to  in  place  of  cauterisation,  so  as  to 
shorten  one  or  other  of  the  walls  of  this  canal.  Marion  Sims  has 
performed  this  operation  three  times  in  cases  where  the  anterior  wall 

1  Comptes  rendus  de  VAcad.  des  scioices,  iev.,  1859. — Philippeaux,  De  la 
cauterisation,  p.  557.     Paris,  1856. 


DEVIATIONS  403 

of  the  vagina  was  extraordinarily  long,  and  appears  to  have  been  suc- 
cessful. There  would  be  less  chance  of  curing  retroversion  by  per- 
forming the  same  operation  on  the  posterior  wall,  and  it  would  be 
more  dangerous  as  I  have  just  explained. 

2.  Treatment  of  Versions  in  particular. 

Having  described  the  course  to  be  pursued  in  the  general  treatment 
of  deviations,  we  must  now  indicate  the  means  to  be  employed  in  the 
special  treatment  of  each. 

I.  Anteversion,  like  anteflexion,  is  normal,  and  continues  to  keep 
this  character  even  when  it  has  attained  a  considerable  degree, 
so  long  as  the  uterus  preserves  its  mobility,  a  proof  of  the  absence  of 
adhesions  and  of  perimetritis.  A  hypogastric  belt  with  a  pad  will 
suffice  to  relieve  the  patient  by  supporting  the  viscera  and  so  prevent- 
ing them  from  pressing  painfully  on  the  posterior  (now  the  superior) 
surface  of  the  uterus.  When  anteversion  is  pathological  and  the 
peritoneal  adhesions  are  in  front  (utero-vesical)  between  the  fundus 
of  the  uterus  and  that  of  the  bladder,  or  behind  (posterior  perime- 
tritis) between  the  cervix  and  the  rectum,  or  if  the  pathological  ante- 
version is  produced  either  by  retraction  and  shortening  of  Douglases 
ligaments  consecutive  to  a  subacute  inflammation,  or  to  a  spasmodic 
contraction  of  these  ligaments,  it  will  always  be  well  to  prevent  the 
viscera  from  painfully  compressing  the  uterus  by  supporting  them  with 
a  hypogastric  belt. 

At  the  same  time  energetic  general  and  local  resolvent  treatment 
should  be  applied  according  to  the  sensitiveness  of  the  patient,  her 
tolerance  and  the  varying  indications  due  to  the  varying  circum- 
stances of  which  I  have  spoken.  Excepting  the  variations  to  be  intro- 
duced into  this  treatment,  we  may  mention :  repeated  laxatives 
and  purgatives,  diuretics,  alteratives  (iodide  or  bromide  of  potas- 
sium long  continued  in  large  doses,  chloride  of  gold  and  sodium,  &c.), 
alkalines,  especially  the  natural  and  artificial  baths  at  Yichy,  with 
vaginal  injections  combined  with  hydropathy,  sometimes  rest  and  the 
dorsal  decubitus  continued  for  long,  or  sedative,  antispasmodic,  alkaline 
injections,  &c.,  on  the  bidet  four  times  a  day,  the  use  of  tampons 
saturated  with  glycerine  or  belladonna,  rectal  injections  of  mercurial 
ointment  mixed  with  laudanum  and  belladonna,  or  a  solution  of  iodide 
of  potassium,  or  suppositories  of  the  same  composition,  sometimes 
with  the  addition  of  hydrate  of  chloral,  chloroform  or  laudanum  as 
antispasmodics,  &c.  Fortunately  version,  when  simple,  after  all  in- 
flammation has  disappeared,  is  not  painful.  By  the  use  of  the  means 
just  mentioned  a  cure  is  generally  obtained;  but  time  is  required,  one 
or  two  years  (two  seasons  at  Vichy),  but  the  long-desired  result  is  at 
length  attained. 

II.  Retroversion  is  alioays  pathological^  for  it  is  the  opposite  of  the 
normal  conditions  of  stability  of  the  organ.  Rupture,  elongation  of 
Douglas's  folds,  relaxation  of  the  retractile  muscles  which  support  the 
uterus  are  the  most  common  causes.  The  use  of  the  sound  is  almost 
always  indispensable  to  reduce  it;    one  or  more  fingers  should  be 


404  UTERINE   DISEASES   IN   DETAIL 

introduced  into  the  posterior  vaginal  cul-de-sac  or  into  the  rectum, 
and  everything  that  is  possible  should  be  done  to  liberate  the  wedged- 
in  organ,  e.g.  evacuate  the  bladder  and  rectum,  not  forgetting  to  make 
the  patient  assume  the  genupectoral  posture. 

The  importance  of  the  genupectoral  posture  in  the  reduction  of 
deviations  and  prolapsus  has  been  explained  by  H.  P.  Campbell.^  It 
is  particularly  useful  in  the  rednction  of  extreme  retroversion,  which  by 
this  posture  becomes  an  automatic  reduction,  to  use  the  author's  own 
expression.  I  have  certainly  seen  the  uterus  replaced  with  great  ease 
when  this  posture  is  assumed :  all  that  is  necessary  is  to  introduce  one 
or  two  fingers  into  the  vagina  so  as  to  separate  the  labia  majora  (the 
patient  can  separate  the  vulval  lips  for  herself  by  means  of  a  simple 
canula),  and  to  allow  the  air  to  penetrate  into  the  vagina.  This  dis- 
placement of  the  centre  of  gravity  and  of  the  weight  of  the  viscera, 
which  have  a  tendency  to  fall  towards  the  umbilicus,  the  traction  exer- 
cised by  the  abdominal  organs  on  the  uterus  by  the  close  contact  of 
the  one  with  the  other,  the  atmospheric  pressure  acting  through  the 
vagina,  which  it  greatly  dilates  in  the  form  of  an  arch,  below  which, 
in  the  most  dependent  part,  the  vaginal  portion  of  the  cervix  is  seen, 
are  the  three  agents  to  which  retroversion  of  the  womb  can  offer  no 
resistance  :  if  reduction  is  not  effected  spontaneously  the  impulse  which 
the  fingers  of  the  physician  give  to  the  uterus  in  forcing  its  fundus  out 
of  the  concavity  of  the  sacrum  obliges  this  organ  to  resume  its  normal 
direction.  I  have  insisted  on  the  possibility  of  reducing  retroversion 
by  this  method  in  order  that  physicians  may  understand  its  importance 
and  explain  it  to  their  patients,  so  that  the  latter  may  be  willing  to 
assume  this  posture  as  well  as  the  abdominal  decubitus,  which  is  so 
useful  to  them.  After  they  have  once  become  accustomed  to  it  they 
are  so  much  relieved  that  they  willingly  continue  it  till  they  are  com- 
pletely cured. 

As  for  the  retention  of  the  uterus  in  its  normal  position,  the  only 
means  of  maintaining  reduction  is  to  keep  the  cervix  back  in  the  sacral 
cavity.  This  can  be  done  by  means  of  a  sponge  {see  Eig.  154,  p.  193) 
or  tampon  saturated  with  a  solution  of  tannic  acid  or  alum,  or  by 
means  of  Hodge's  pessary,  as  modified  by  myself,  which  forces  the 
cervix  to  remain  against  the  sacrum. 

It  is  well  to  use  both  alternately ;  the  pessaries  retain  the  cervix 
better,  whilst  plugs  have  the  advantage  of  conveying  astringent  applica- 
tions to  these  parts  suitable  for  inducing  contractility  in  Douglas's 
ligaments  and  determining  retraction  or  shortening,  the  only  and  indis- 
pensable condition  of  permanent  replacement  of  the  organ.  The  good 
of  these  pessaries  and  tampons  is  that,  by  retaining  the  cervix  in  the 
sacral  cavity  they  force  the  fundus  forward,  and  so  the  whole  organ 
resumes  its  normal  direction  of  anteversion;  the  abdominal  viscera, 
which  formerly  increased  the  retroversion,  contribute  now,  on  the  con- 
trary, by  their  pressure  on  the  posterior  (now  superior)  surface  of  the 

^  Pneumatic  self  replacement  in  dislocations  of  the  gravid  and  non-gravid 
uterus  {Transactions  of  the  American  Gynecological  Society,  vol.  i,  p.  193. 
Boston,  1877). 


DEVIATIONS  405 

uterus^  to  maintain  this  organ  in  the  natural  position  to  which  we  have 
restored  it.  When  the  patient  is  not  standing  she  ought  to  assume 
the  abdominal  decubitus,  which  forces  the  fundus  to  gravitate 
downwards. 

It  is  important  to  ensure  the  persistency  of  the  reduction  by  using 
all  possible  means  to  excite  the  contraction  of  the  ligaments  and  bring 
about  their  shortening:  astringents  (alum,  tannin,  rhatany,  &c.)  applied 
to  the  posterior  cul-de-sac  of  the  vagina,  round  the  vaginal  portion  of 
the  uterus,  or  ergot  taken  in  doses  of  from  four  to  eight  grains  three 
or  four  times  a  day  for  five  or  six  days,  and  repeated  after  a  week's 
interval;  the  application  of  electricity  by  the  interrupted  current,  one 
of  the  poles  being  applied  to  the  lumbo-sacral  region,  the  other  round 
the  cervix;  immersion  in  a  cold  sitz-bath  six  times  a  day;  hydropathy, 
cold  and  astringent  vaginal  injections,  sea  bathing,  salt  or  aromatic 
baths  or  tonic  and  exciting  frictions  of  the  whole  body  every 
morning. 

"When  retroversion  has  become  irreducible  owing  to  the  formation  of 
adhesions  as  a  consequence  of  posterior  perimetritis,  the  deviation  is 
doubly  pathological;  pathological  by  its  direction  which  is  absolutely 
the  reverse  of  the  normal  state,  pathological  by  the  inflammation  which 
now  complicates  the  retroversion,  and  sometimes  is  even  in  part  the 
cause  of  it.  These  peritoneo-cicatricial  bands  not  only  constitute  a 
malady  in  themselves, .  but  they  form  a  pathological  condition  in  a 
second  way,  viz.  as  causes  of  irreducibility,  and  in  a  third  sense  by 
continually  threatening  a  return  of  inflammation,  all  the  more  easily 
produced  in  that  the  compression,  dragging  and  shocks  which  the 
uterus  receives  from  or  produces  on  the  neighbouring  organs  in  its 
vicious  position  (for  the  adhesions  involve  the  contact  of  the  fundus 
with  the  lowest  portion  of  Douglas's  cul-de-sac')  are  so  many  exciting 
causes  of  a  fresh  outburst  of  inflammation. — Therefore  these  retro- 
versions are  almost  as  painful  as  retroflexions.  The  extremely  low  posi- 
tion of  the  fundus  near  the  perinseum  and  anus,  the  weight  and  the 
inflammatory  pain  of  this  heavy  part,  the  pain  produced  by  the  least 
shock  or  dragging  on  the  adhesions  (and  every  movement  occasions 
dragging  or  shock),  continually  provoke  the  slow  return  or  sudden 
outburst  of  new  pain. — Therefore  the  most  energetic  antiphlogistic 
and  resolvent  treatment  must  be  associated  with  a  wise  mechanical 
treatment,  according  to  the  indication  and  the  variations  which  it  must 
undergo,  depending  on  the  stage  of  the  malady. 

At  the  commencement,  antiphlogistics,  sometimes  leeches,  repeated 
laxatives,  rectal  injections  of  resolvent  and  sedative  ointment  {^see 
p.  185)  applied  twice  a  week,  alkaline,  gelatinous,  emollient  and  seda- 
tive baths  every  day  for  several  hours'  duration  with  vaginal  injections 
all  the  time,  and  the  abdominal  decubitus,  with,  later  on,  Vichy  waters 
and  hydropathy,  bromide  and  iodide  of  potassium,  sometimes  even 
blisters  on  the  loins,  thighs  or  sacrum,  produce  astonishing  results. 
We  find  after  repeated  attempts  to  efl'ect  reduction  that  the  deviation 
becomes  gradually  mobile,  moving  gently  under  the  simultaneous 
pressure  of  both  hands,  and  sometimes  in  the  end  allowing  of  reduc- 


406  UTEEINE    DISEASES    IN    DETAIL 

tion  with  the  help  of  the  sound  :  these  cases  I  admit  are  rare^  but  they 
are  to  be  met  with  in  young  women,  and  it  is  a  great  matter  to  know 
that  such  a  deviation  when  taken  early  is  not  incurable. — It  is  evident 
that  as  long  as  the  retroversion  remains  irreducible  it  is  useless  to 
struggle  against  the  adhesive  perimetritis  by  the  use  of  instruments 
for  restoring  the  uterus  to  position,  the  only  effect  of  which  would  be 
to  keep  up  and  to  increase  the  inflammation.  Patients  may,  however, 
be  relieved  by  the  use  of  a  perinseal  pad  attached  to  a  good  belt  (not 
a  hypogastric  belt  with  pad),  which  raises  the  perinseum,  the  pouch  of 
Douglas  and  the  body  of  the  uterus ;  whilst  the  inflammation  and  the 
adhesions  produced  by  it  are  placed  in  the  state  of  absolute  rest  which 
is  required  by  all  inflamed  organs. — When  the  adhesions  have  disap- 
peared and  replacement  is  obtained,  reduction  should  be  repeated  as 
often  as  necessary,  and  the  patient  should  be  taught  to  do  it  herself 
with  the  help  of  her  nurse  or  husband,  according  to  Campbell's 
method,  by  assuming  the  genupectoral  posture  at  bedtime,  and  the 
abdominal  decubitus  all  the  night.  The  reduction  should  be  main- 
tained as  much  as  possible  during  the  day  by  the  use  of  my  pessary, 
whilst  contraction  of  the  suspensory  ligaments  and  of  the  uterine  tissue 
itself  may  be  excited  by  introducing  the  galvanic  intra-uterine  stem 
for  a  few  hours  once  or  twice  a  week.  The  treatment  of  retroversion 
is  more  difficult  than  that  of  any  other  version,  and  in  many  cases  we 
have  to  content  ourselves  with  a  palliative  cure  ;  nevertheless,  so  much 
progress  has  been  made  in  this  department  of  medicine  during  the  last 
few  years  by  patient  investigation  of  the  anatomical  alterations  which 
are  the  causes  of  this  malady,  that  we  have  reason  to  hope  we  may 
obtain  a  large  number  of  cures  in  the  future. 

III.  Latero-versions  are  always  pathological,  whether  simple,  i.  e. 
determined  by  the  simultaneous  contraction  of  the  posterior  ligaments 
and  the  broad  ligaments  of  the  same  side,  or  complex,  with  torsion  of 
the  axis,  determined  by  contraction  of  one  of  Douglas's  ligaments  on 
one  side  and  one  of  the  broad  ligaments  on  the  other.  In  all  cases 
there  has  been  parametritis  or  perimetritis,  spasmodic  contraction  and 
retraction,  either  cicatricial  or  consequent  to  subacute  or  chronic  in- 
flammation. There  is  really  no  other  treatment  for  it  than  that  which 
I  have  already  indicated  for  pathological  anteversion  (p.  408). 

Elexions 

1.  Flexions  in  General 

Flexions,  inflexions,  incurvations  of  the  uterus  are  alterations  in  the 
direction  of  the  various  parts  of  the  axis  of  this  organ  with  regard  to 
each  other.  According  to  my  experience  they  are  more  common  than 
versions.  They  involve  a  modification  in  the  form  of  the  organ,  but  do 
not  imply  a  change  in  its  position  or  direction.  The  uterus  may 
remain  in  its  normal  position  whilst  bent  on  itself,  or  it  may  simulta- 
neously experience  a  double  or  treble  change  in  its  form,  direction  and 
position.  It  must  be  admitted  that  version  and  flexion  of  the  same 
side  are  met  with  more  frequently  combined  than  separately.     They 


FLEXIONS  407 

may  be  congenital  or  accidental,  simple  or  complex,  having  their  seat 
at  one  point  or  another  and  at  various  degrees,  bending  the  organ 
forwards,  backwards,  or  on  one  side. 

Congenital  flexions  occur  from  inequality  of  development  or  imper- 
fection of  histological  formation. — Accidental  or  acquired  flexions 
involve  a  predisposition  and  a  determining  cause  or  pathological  altera- 
tion. They  are  the  consequence  of  the  accomplishment  of  the  uterine 
functions  and  of  modifications  produced  in  the  tissue  of  the  organ  : 
menstruation,  pregnancy,  delivery,  abortion,  predispose  to  them  in  con- 
sequence of  the  tumefaction  of  the  organ,  the  increased  size  of  its  cavity, 
the  relative  defect  in  the  resistance  of  its  walls,  the  alteration  of  its 
constituent  elements,  &c, ;  so  that  a  very  slight  cause,  a  vicious  posi- 
tion, pressure  or  shock,  may  suffice  to  flex  the  organ  on  itself,  owing 
to  defective  resistance  of  its  tissue.  Lastly,  a  uterine  or  peri-uterine 
pathological  alteration  may  produce  the  same  eflfect  independently  of 
any  predisposition :  a  partial  tumefaction  of  the  softened  organ,  the 
unequal  increase  of  size  in  the  two  segments,  a  retraction  or  partial 
fibrous  transformation  of  one  of  the  uterine  walls,  a  fatty  degeneration 
and  defective  resistance  of  the  tissue  at  the  isthmus  or  some  other 
point,  the  elongation  of  the  uterus  or  of  one  of  its  parts,  peri-uterine 
inflammation  and  its  consequences,  peritonitis  whilst  the  fundus  is  in 
retroversion  or  after  labour  and  the  formation  of  adhesions  between  the 
fundus  and  the  utero-rectal  cul-de-sac,  preventing  the  replacement  of 
the  body  whilst  the  cervix  may  resume  its  normal  direction  :  such  are 
the  causes  which  may  flex  the  uterus  on  itself. 

Simple  flexions  are  rare,  complications  usually  occurring  as  conse- 
quences, if  they  had  not  previously  existed  as  causes. — Flexions  with 
complications  are  more  common.  Amongst  the  maladies  which  most  fre- 
quently coexist  with  flexions  are  :  uterine  and  peri-uterine  inflammation ; 
total  or  partial  hypertrophic  elongation  of  the  uterus  ;  peritoneal  adhe- 
sions between  the  fundus  or  body  of  the  uterus  and  the  neighbouring 
organs;  engorgement,  chronic  congestion,  repeated  fluxions;  tumours  of 
various  kinds,  intra-  or  extra-uterine,  which  may,  by  increase  of  weight  or 
pressure  or  from  being  wedged  in,  keep  the  uterus  flexed  on  itself ;  lastly 
deviations  and  displacements,  which  may  coexist  with  flexions  either 
together  or  separately,  so  that  prolapsus,  retroversion  and  retroflexion 
may  be  met  with  simultaneously.  These  complications  are  so  frequent 
that  several  writers  describe  flexions  with  versions'  and  other  mechanical 
lesions  of  the  womb;  but  although  this  combination  is  frequently 
found  in  nature  they  should  not  be  confused  together  in  a  common 
description.  Other  physicians,  rightly  appreciating  the  great  sym- 
ptomatic difference  which  exists  between  anteversion  and  retroversion, 
anteflexion  and  retroflexion,  as  well  as  the  analogies  between  ante- 
flexion and  anteversion,  retroflexion  and  retroversion,  as  concerns 
diagnosis  and  treatment,  have  given  a  common  description  of  inclina- 
tions forwards  (flexions  and  versions)  and  of  inclinations  backwards 
(flexions  and  versions) ;  it  seems  to  me,  however,  that  what  i-^  gained 
on  the  one  hand  by  bringing  together  lesions  which  furnish  similar  in- 
dications, is  lost  on  the  other  by  separating  maladies  giving  rise  in  many 


408  UTERINE   DISEASES    IN    DETAIL 

points  to  common  symptoms.  Their  coincidence  can  be  seen  and 
explained.  Thus,  when  flexion  is  very  marked,  especially  backwards, 
it  increases  the  weight  of  the  uterus  and  gradually  determines  retro- 
version ;  this  retroversion  becomes  permanent  owing  to  the  elongation 
caused  by  continuous  traction  on  the  uterine  ligaments.  This  will  be 
still  more  the  case  when  flexion  is  produced  after  delivery,  when  the 
ligaments  are  soft  and  relaxed  like  the  tissue  of  the  uterus  itself; 
hence  retroflexion  and  retroversion  are  often  met  with  simultaneously, 
for  the  same  cause  produces  the  same  effects  on  the  uterus  and  on  the 
ligaments,  so  that  the  organ  is  both  flexed  and  deviated.  In  many 
other  circumstances,  however,  especially  in  congenital  flexions,  the 
bent  uterus  is  not  deviated;  the  tissue  of  the  organ  only  is  altered, 
that  of  its  ligaments  being  healthy. 

The  seat  of  the  flexion  is  variable.  Usually  it  is  at  the  isthmus. 
The  flexed  uterus  resembles  a  chemical  retort.  The  reason  why  flexion 
occurs  most  frequently  at  this  point  will  be  found,  according  to 
Virchow,  in  the  adhesions  between  the  neck  and  the  bladder.  I  think 
a  stronger  reason  may  be  given,  viz.  the  relative  defective  resistance  of 
tissue  at  this  point  of  junction  of  two  different  organs  (body  and 
neck)  united  into  one  (uterus).  It  must  not,  however,  be  thought  that 
it  is  always  so,  and  that  uterine  flexion  necessarily  means  flexion  of  the 
body  on  the  neck.  The  alteration  of  tissue,  weakness  or  contraction, 
may  be  only  in  the  body  or  only  in  the  neck.  Why  should  we  not 
admit  this  when  we  know  that  it  is  often  produced  on  one  of  the  seg- 
ments of  the  uterus,  the  anterior  or  posterior,  to  the  exclusion  of  the 
other,  and  even,  according  to  Martin,  on  one  part  of  a  segment  (the 
seat  of  "the  placenta)  to  the  exclusion  of  the  others  ?  Thus  there  are 
flexions  of  the  body  and  flexions  of  the  neck.  Further,  the  flexion  may 
affect  both  body  and  neck.  In  the  latter  case  it  is  produced  in  the 
same  direction,  and  gives  to  the  uterus  a  horseshoe  curve,  the  two  ex- 
tremities of  which,  fundus  and  os,  are  directed  to  the  same  side,  a 
deformity  usually  congenital,  especially  in  anteflexion ;  but  it  some- 
times happens  that  two  flexions  are  produced  in  opposite  directions, 
e.g.  curving  the  body  backwards  and  the  neck  forwards,  so  that  the 
fundus  and  cervix  look  in  opposite  directions,  and  the  uterus,  as  a 
whole,  takes  the  form  of  an  S. 

Whether  the  flexion  have  its  seat  on  the  isthmus  or  on  one  of  the 
segments  of  the  uterus,  it  may  vary  in  degree,  from  the  slightest  curve 
to  the  most  marked  flexion,  the  two  portions  of  the  organ  forming 
between  them  an  obtuse  angle  in  the  first  case,  and  an  acute  angle  in 
the  second.  Curvature  or  inflexion  is  almost  a  physiological  state, 
especially  when  it  is  forwards ;  it  is  very  common,  and  is  frequently 
associated  with  deviations. 

Flexion  properly  so  called  is  very  frequent.  It  may  require  the  help 
of  art  and  derive  benefit  from  it. — Under  the  name  of  infraction 
Sommer^  has  described  the  very  rare  state  in  which  the  uterus  is  flexed 

^  Beitrdge  zur  Lehre  der  Infractionen  und  Flexionen  der  Gebdrmutter, 
Deutsche  KliniJc,  1850,  S.  276.  Quoted  by  Paul  Picard,  Des  inflexions  de 
I'uterus  a  I'etat  de  vacuite.  Paris,  1862. 


FLEXIONS 


409 


Fig.  267.— Flexion  of  the  neck 
forwards  with  conical  neck 
and  narrow  os. 


on  itself  to  such  an  extent  that  the  two  portions  of  the  same  surface 
become  parallel  and  contiguous. 

Lastly,  whatever  the  seat  or  the  de- 
gree, flexion  may  take  place  in  different 
directions. 

Flexion  of  the  necTc,  the  importance 
of  which  seems  to  have  been  exag- 
gerated in  America,^  seems  almost  al- 
ways in  one  direction,  viz.  forwards;  it 
also  usually  coincides  with  anteflexion 
of  the  body,  as  well  as  with  elongation 
of  the  neck,  narrow  os,  and  several  of  the 
conditions  of  mechanical  dysmenorrhcea. 
According  to  the  authors  who  have  de- 
scribed it,  it  is  the  most  common  of  all. 
Flexion  of  the  body  is  more  variable. 

Sometimes  it  is  forwards  and  goes  by 
the  name  of  anteflexion,  which  is  the  most 
common  amongst  nuUiparse.  In  the  foetus 
this  disposition  may  be  regarded  as  nor- 
mal, and  depends  either  on  the  imperfect 
development  of  the  anterior  wall  at  that 
age,  or  on  the  thinness  and  softness  of  the 
body  coinciding  with  thickness  and  rigi- 
dity of  the  neck  ;  in  the  adult  it  often  depends  on  the  persistence  of  this 
fcetal  disposition  or  on  the  retraction  of  the  tissue  of  the  anterior  segment 
of  the  organ,  as  well  as  of  the  utero-sacral  ligaments,  consequent  on 
retro-uterine  inflammation,  which  has  procured  for  this  variety  the  name 
of  pathological,  as  distinguished  from  congenital,  anteflexion.  The  fun- 
dus touches  the  upper  surface  of  the  bladder  ;  the  neck  rests  in  the  axis 
of  the  vagina,  lower  than  or  on  a  level  with  the  fundus,  according  to 
the  degree  of  the  flexion ;  usually  it  is  flexed  forwards,  i.  e.  in  the  same 
direction  as  the  fundus,  in  the  form  of  a  horseshoe,  very  seldom  back- 
wards, in  the  form  of  the  letter  S. 

Sometimes  it  is  backwards,  and  is  then  designated  retroflexion. 
Seldom  congenital,  and  therefore  less  frequent  than  anteflexions,  occur- 
ring generally  after  delivery  or  miscarriage,  i.  e.  usually  pathological 
and  more  common  then  than  pathological  anteflexion,  often  met  with 
in  old  women,  it  necessarily  involves  a  softening  of  the  tissue  on  a 
level  with  the  isthmus  or  with  the  seat  of  the  curvature,  relaxation  or 
elongation  of  the  suprapubic  ligament,  rupture  or  distension  of  the 
utero-sacral  ligaments  ;  in  short,  the  opposite  of  anteflexion.  The 
fundus  rests  on  the  anterior  surface  of  the  rectum,  in  the  peritoneal 
vagino-rectal  cul-de-sac  (Fig.  1),  where  it  may  be  easily  felt,  either 
through  the  vagina  or  through  the  rectum,  sometimes  higher  than  the 
neck,  sometimes  on  the  same  level,  sometimes  lower.     Tlie  neck  may 

^  Emmet,  The  Etiology  of  Uterine  Flexures,  with  the  Proper  Mode  of 
Treatment  Indicated  {Transactions  of  the  American  Gynecological  Society, 
vol.  i,  p.  48.  Boston,  1877). 


410 


UTEEINE    DISEASES   IN    DETAIL 


also  be  flexed  in  the  same  direction  or  in  the  opposite  one ;  but  this 
coincidence  of  flexion  of  the  neck  with  that  of  the  body  occurs  less 


Fig.    268. — Anteflexion    sup-  Fig.  269. — Extreme  retroflexion,  present- 

posed  to  be  congenital,  in  ing  occlusions  at  several  points  in  the 

a  girl  of  eighteen   (after  canal  or  cavity  of  tlie   uterus.     Pre- 

Boivin  and  Duges).  paration  in  the  Middlesex  Hospital 

(after  Barnes). 

frequently  in  retroflexion  than  in  anteflexion.  Statistics  show  that  re- 
troflexion is  much  more  frequent  than  anteflexion  in  multiparse ;  whilst 
all  the  physiological  dispositions  tend  to  anteflexion  and  anteversion, 
all  the  pathological  causes  incline  to  retroflexion  and  retroversion. 

In  latero-fiexions  and  in  intermediate  curvatures  the  fundus  of  the 
uterus  is  discovered  by  exploring  on  each  side  of  the  neck  or  of 


Fig.  270. — Uterus  strongly  inclined  to  the    right,    or  appearance  of    dextro- 
flexion.     Probably  the  left  side  is  imperfectly  developed  (after  Tiedeman). 

Douglases  ligaments,  as  we  try  to  depress  the  lateral  vagino-uterine 
sinus  with  the  finger.  These  flexions  are  much  rarer  than  the  pre- 
ceding, and  always  result  from  some  anomaly  or  pathological  condition 
of  the  ligaments  or  of  the  two  segments  of  the  uterus  (Fig.  270). — 
Torsion  of  the  uterus  is  still  rarer;  iL  coincides  with  latero-flexions 
and  seems  to  depend  on  the  same  causes,  especially  on  the  alteration 


FLEXIONS 


411 


and  change  in  the  length  of  the  hgaments  of  one  side  occurring  at  the 
same  time  with  softening  of  the  tissue  of  the  uterus  (Fig.  271). — 
Alterations  of  the  tissue  of  the  uterus,  ligaments  or  neighbouring  parts, 
and  the  other  uterine  lesions  concomitant  with  flexions,  are  variable 
in  different  flexions,  in  the  same  flexion  at  different  periods,  and  in 
different  women. 

In  the  first  place  one  of  the  alterations  must  have  existed  before  the 
uterus  could  become  bent  on  itself;  in  the  second  place  the  uterus 
cannot  long  remain  flexed  in  the  period  of  sexual  activity  without, 
under  the  influence  of  menstruation,  coitus,    &c.,    and  by   the  fact 


Fig.  271. — Dextroflexion  and  torsion  of  tlie  uterus  from  right  to  left.  Pre- 
paration in  the  College  of  Sui'geons,  London,  by  Protheroe  Smith  {British 
Medical  Journal,  1872,  vol.  i,  p.  517),  after  Beigel,  op.  cit.,  vol.  ii,  p.  218, 
1875.  c,  neck,  with  a  probe  introduced  to  indicate  the  direction  of  the 
canal  ;  i,  point  of  flexion  at  the  union  of  the  body  and  neck  ;  f,  fundus  ; 
T,  left  Fallopian  tube  ;  o,  right  ovary,  diseased  ;  t',  right  Fallopian  tube, 
diseased. 

of    its    flexion,    producing    some    alteration    in    its    substance    or 
surroundings. 

The  increased  size  of  the  uterus,  the  elongation  of  its  longitudhial 
diameter,  the  softening  of  its  tissue,^  especially  at  the  isthmus  which 
is  the  thinnest  portion  of  the  organ,^  the  coincidence  of  these  altera- 
tions with  elongation,  laxity  or  atony  of  the  means  of  suspension, 
especially  of  the  utero-sacral,  broad  and  round  ligaments  are  very 
favorable  if  not  necessary  conditions  in  the  production  of  uterine 
flexions.  This  is  why  flexions  so  often  occur  after  delivery  or  abor- 
tions,^ and  why  in  such  cases  flexions  are  seen  combined  with  versions, 

1  Kiwisch,  Die  Kranhheiten  der  GehdrTmdter,  Bd.  i,  S.  101.  Prague,  1851. 

2  Rokitanski,  Anat.  patJiol.,  t.  iii,  p.  457. 

^  Scanzoni  (op.  cit.  p.  8G)  and  Nonat  (op.  cit.,  p.  495)  rightly  observe  that 
abortion  is  more  favorable  to  flexions  than  the  puerperal  condition,  because  in 


412  UTERINE    DISEASES    IN    DETA.1L 

anteflexion  with  anteversion,  retroflexion  witTi  retroversion.  This  is 
also  why  the  adhesions  and  cicatricial  bands  which  are  produced  after 
puerperal  metro-peritonitis  themselves  become  causes  of  flexions  all 
the  more  hurtful  because  they  give  a  fixed  and  irreducible  curve  to 
the  organ.  Yirchow/  however,  has  exaggerated  the  importance  of 
these  peritoneal  alterations  in  attributing  to  them  the  majority  of 
uterine  flexions. 

It  is  not  necessary  for  the  uterine  tissue  to  be  really  altered  to  allow 
of  a  flexion  taking  place ;  but  even  in  cases  where  the  uterine  tissue 
seems  to  be  exempt  from  any  alteration,  and  when  the  flexion  is  un- 
observed, there  must  be  some  cause  for  it.  This  cause,  in  foetal  life 
and  in  childhood,  seems  to  be  the  relative  shortness  of  one  wall  (in 
the  case  in  question  the  anterior  wall,  hence  anteflexion) ;  afterwards 
it  may  be  traced  to  the  relative  thinness  and  weakness  of  the  isthmus 
and  to  the  indifference  of  position  of  the  fundus  which  yields  to 
pressure  from  the  neighbouring  organs,  or  to  the  relative  weight  of  the 
body  of  the  organ,  which,  having  a  greater  tendency  in  some  cases 
(especially  after  labour)  to  incline  backwards,  and  finding  no  obstacle 
in  any  direction,  falls  more  and  more  behind  the  neck  into  the  pouch 
of  Douglas.  In  early  age  the  cervix  offers  more  resistance  than  the 
body  to  displacements  caused  by  pressure  from  the  neighbouring 
viscera.  The  body,  which  is  free,  independent,  and  attached  to  the 
neck  by  a  narrow  portion,  is,  on  the  contrary,  inclined  to  yield  to  the 
influence  of  this  pressure  and  to  incline  forwards  in  growth,  more  fre- 
quently backwards  in  advanced  life,  version  being  very  often  combined 
with  flexion  in  the  same  direction.  There  is,  then,  even  in  those  kinds 
of  flexion  which  are  not  pathological  when  compared  with  the  flexions 
properly  so  called  of  adult  age,  a  diminution  in  the  relative  resistance 
of  the  various  portions  of  the  uterine  tissue  which  accounts  for  the 
flexion. 

An  alteration  may  even  be  produced  in  this  tissue  which  I  would 
call  active  in  comparing  it  with  the  passive  alteration  of  defective  re- 
sistance ;  I  mean  the  shortening  of  one  of  the  segments  of  the  uterus, 
due  to  the  inequality  of  their  development  from  defective  organisation 
in  the  uterine  tissue,  to  the  contraction  or  retraction  of  its  fibres,  to 
the  production  of  inodular  interstitial  tissue  in  its  thickness.  It  is  to 
this  cause  that  we  may  attribute  the  abnormal  persistency  of  foetal 
anteflexion  (Cusco),  some  flexions  of  old  age,  and  especially  those  rare 
but  authentic  cases  in  which  flexion,  in  place  of  occurring  at  the  union 
of  body  and  neck,  only  affects  the  body,  or  the  neck,  or  both  at  once, 
either  in  the  same  or  in  a  contrary  direction.  I  have  lately  seen  a 
case  of  retroflexion  at  the  menopause  which  I  could  only  attribute  to 
atrophy  of  the  posterior  segment  of  the  uterus,  especially  on  a  level 
with  the  isthmus.     Whether  these  alterations  of  tissue  have  or  have 

tte  first  months  of  pregnancy  only  the  body  of  the  uterus  is  developed,  while 
the  neck  is  more  firmly  retained  by  vaginal  adhesions  and  the  isthmus  relatively 
narrower  and  less  resistant  than  at  a  later  period. 

'   Ueber  die  KnicJcungen  der  Gebar'inutter,   Verhandl.  der   Gesellsch.  fur 
GehurtsJc.,  iv,  80. — Gesammelte  Abhandlung,  ii,  822. 


FLEXIONS 


413 


not  preceded^  prepared  and  determined  the  flexion,  they  do  not  fail  to 
accompany  it. 

The  investigations  which  I  have  made  on  the  alteration  which  the 
tissue  of  the  uterus  may  undergo  on  a  level  with  the  curvature  and  on 
the  side  of  the  flexion  have  proved  to  me,  as  to  Eobin,  Aran,  Virchow, 
Sommer,  Scanzoni,  that  there  is  either  a  softening  of  the  uterine  tissue, 
which  in  this  case  is  pale  and  its  muscular  fibres  scarce  or  infiltrated 
with  fat,  as  in  the  period  of  retrograde  evolution  after  delivery,  or  else 
a  retraction  of  this  tissue,  which  is  then  hard,  resistant  and  fibrous, 
like  a  cicatricial  band  (Fig.  272).  It  cannot  be  denied  that  the  mus- 
cular tissue  often  becomes  gradually  thinner  at  the  seat  of  flexion. 


Fig,  272. — Ketroflexion  in  the  second  degree,  with  persistence  of  the  cervico- 
uterine  canal  (after  Graily  Hewitt). 

being  changed  into  soft  cellular  and  fibrous  tissue,  which  weakens  and 
shortens  the  flexed  wall,  thereby  ensuring  the  permanence  of  the 
flexion.  Hence,  in  my  opinion,  the  indication  to  stimulate  the  con- 
tractility of  this  tissue  and  to  excite  hypertrophy  in  order  to  cure 
the  flexion. 

When  the  flexion  takes  place  at  the  isthmus  it  necessarily  narrows 
the  OS  internum.  This  diminution  of  size,  which  is  at  first  purely 
mechanical,  may  afterwards  become  organic  and  permanent  (Fig.  273). 
The  wall  of  this  orifice  corresponding  to  the  retreating  angle  of  the 
flexion,  forms  a  projecting  angle,  a  kind  of  spur,  which  makes  the 
passage  of  menstrual  blood  and  leucorrhoeic  mucus  from  the  cavity  of 
the  body  into  that  of  the  cervix  difficult,  and  the  use  of  the  sound 
still  more  so.  It  is  easy  to  understand  how  this  difficulty,  which  is 
overcome  by  uterine  contractions  during  the  period  extending  from 
puberty  to  the  menopause,  remains  purely  mechanical,  the  width  and 
dilatability  of  the  orifice  being  presented  by  the  expulsion  of  blood 
at  the  monthly  period.  But  it  is  also  evident  that,  during  this  period, 
especially  in  early  youth  and  old  age,  it  must  often  happen  that  the 
gradual  alteration  of  tissue,  especially  of  the  fibrous  tissue  at  the  point 


414 


UTEEINE    DISEASES    IN   DETAIL 


of  flexion,  must  end  by  causing  this   organic  contraction,    and  by 
gradually  producing  obliteration. 

The  influence  due,  on  the  one  hand,  to  external  pressure,  and  on  the 
other  to  softness  of  tissue  or  muscular  contraction  and  retraction, 
accounts  for  one  way  in  which  alteration  of  the  uterine  axis  is  pro- 
duced. I  refer  to  torsion  of  this  axis  caused  by  a  rotatory  movement 
in  an  opposite  direction  of  the  neck  on  the  body,  or  more  frequently 
of  the  body  on  the  neck.  I  have  seen  numerous  examples  of  this  kind 
of  torsion,  which  is  a  common  cause  of  sterility,  and  which  I  have  suc- 


FiG.  273. — Eetroflexion  in  tte  third  degree,  with  occlusion  of  the  cervico- 
uterine  canal  owing  to  the  close  juxtaposition  of  the  walls  (after  GraUy 
Hewitt).  In  this,  as  in  the  preceding  figure,  the  uterine  tissue  is  pale  and 
anseniic  at  the  point  of  flexion. 

ceeded  in  curing  by  progressive  dilatations ;  it  is  easily  recognised  by 
the  spiral  direction  which  has  to  be  given  to  the  sound  to  allow  of  its 
passing  from  the  cavity  of  the  neck  into  that  of  the  body,  and  it  often 
coincides  with  anteflexion  or  retroflexion.  Like  flexions,  it  depends 
on  the  inequality  of  visceral  pressure  exercised  on  the  two  borders  as 
on  the  two  surfaces  of  the  uterine  body,  or  on  an  inequality  in  the 
shortening  of  the  round  or  broad  ligaments,  which  is  more  serious,  as 
in  this  case  the  torsion  may  be  irreducible.  Lastly,  the  tissue  of  the 
uterus,  when  softened,  congested,  or  otherwise  altered  before  flexion, 
has  a  tendency  to  become  increasingly  so  from  the  effect  of  the  flexion. 
In  cases  where  there  was  no  change,  as  in  flexions  occurring  in  early 
life,  the  uterus  may  remain  for  some  time  without  undergoing  any 
of  these  alterations;  but  it  is  seldom  that  it  does  not  ui  the  end 
become  affected,  either  from  the  fact  of  the  declivity  of  the  fundus,  the 
difficulties  placed  in  the  way  of  circulation  and  all  the  conditions  which 
favour  its  passive  congestion,  or  above  all  from  the  effect  of  uterine 
fluxion  at  every  menstrual  period,  from  the  difficulty  with  which  the 


FLEXIONS 


415 


blood  is  expelled  from  its  cavity,  from  the  modifications  produced  in 
the  womb  by  pregnancy,  from  the  accidents  following  delivery,  &c. 
In  consequence  of  these  modifications  and  others  occurring  in  the 
immediate  neighbourhood  a  great  many  complications  are  produced 
which  have  to  be  taken  into  account  in  diagnosis  and  treatment. 

Therefore  in  the  adult  woman  retroflexion,  which  is  frequent^  in 
proportion  to  the  number  of  rapidly  succeeding  pregnancies  and  the 
degree  in  which  the  uterine  tissue  has  been  altered,  is  in  its  turn  fre- 
quently followed  by  chronic  congestion,  softening,  hypertrophy,  uterine 
leucorrhoea,  granulations,  ulcerations,  uterine  and  peri-uterine  inflam- 
mation extending  even  to  the  appen- 
dages, and  hard  inflammatory  swellings, 
or  latero-  and  retro- uterine  adenitis, 
limited  peritonitis,  adhesions,  the  for- 
mation of  bands  keeping  the  fundus 
attached  to  the  neighbouring  parts,^ 
prolapsus  of  the  ovary,  &c.  There  are 
great  differences  in  patients.  In  some, 
flexion  may  have  existed  for  a  number 
of  years  without  the  uterus  having  con- 
tracted adhesions  with  the  neighbouring 
parts  and  having  ceased  to  be  redu- 
cible. In  others  adhesions  may  exist 
from  the  commencement,  having  been 
formed  at  the  same  time  as  the  retro- 
flexion was  produced ;  or  it  may  be 
that  the  uterus,  which  for  years  had 
remained  reducible,  becomes  in  the  end 
adherent  to  the  rectum  or  to  Douglas's 
ligaments,  as  a  consequence  of  peri- 
uterine peritonitis. 

Consequently,  there  are  three  causes 
which  render  flexions  permanent :  1, 
the  alteration  of  the  tissue  at  the  point  of  flexion ;  2,  adhesions 
between  the  fundus  and  the  rectum  or  bladder;  3,  the  consecu- 
tive atrophy  of  the  uterine  wall  at  the  side  of  the  flexion.  The 
chief  effects  on  the  uterus  are  :  1,  contraction  of  the  os  internum,  not 
only  mechanical  but  organic,  produced  by  the  constant  irritation  and 
thickening  of  the  mucous  membrane  at  this  point,  or  retraction  of  the 
muscular  fibres ;  the  tendency  to  obliteration  during  old  age  is  pro- 
bably increased;  2,  congestions  and  menorrhagic  tendencies;  3,  excen- 
tric  hypertrophy,  the  dilatation  of  the  cavity  of  the  body  by  retention 
of  the  secretions.  The  neck,  too,  is  sometimes  irritated,  secreting 
mucus,  with  red  and  eroded  borders,  half  opened  orifice  and  unequal 

'  Scanzoni,  op.  cit.,  p.  86. 

^  Picard  (op.  cit.)  has  two  woodcuts  of  two  anatomical  preparations  of  flexions 
rendered  irreducible  by  membranous  adhesions  to  the  neiglibouring  parts  :  an 
anteflexion  with  utero-vesical  peritoneal  bands,  and  a  retroflexion  with  utero- 
rectal  membranous  adhesions. 


Fig.  274. — Torsion  of  the  body- 
on  the  neck  and  contraction 
of  the  isthmus,  seen  in  a  mul- 
tipara of  thirty-five  years. 


416 


UTEEINE    DISEASES    IN    DETAIL 


lips,  the  anterior  shorter  and  smaller  than  the  posterior  in  retroflexion 

(Soramer,  West),  the  posterior  less  in  anteflexion ;  in  short,  the  thickest 

lip  is  the  one  corresponding  to  the  flexion. 

As  to  the  diff'erence  in  fre- 
quency and  gravity  latero-flex- 
ions,  which  seem  to  coincide 
with  a  shortening  of  one  of  the 
broad  ligaments  are  excessively 
rare;  retroflexion  is  frequent  in 
the  adult  after  delivery  and  even 
in  the  aged;  I  have  also  seen 
cases  occurring  in  young  girls 
and  in  sterile  married  women; 
flexion  of  the  cervix  is  common 
in  youth  at  the  time  of  puberty ; 
but  anteflexion,  which  is  almost 
the  only  one  seen  in  childhood, 
is  on  that  account  the  most  com- 
mon of  all.  At  the  same  time 
anteflexion  is  never  so  marked  as 
retroflexion  ;  for  there  is  nothing 
behind  to  check  prolapsus  of  the 
body,  whilst  in  front  it  is  limited 
by  the  bladder,  and  on  the  sides 

by  the  lateral  ligaments  (broad  ligaments) . 


Fig.  275. — Retroflexion  in  the  second 
degree  :  projecting  spur,  partial  hy- 
pertrophy of  the  posterior  lip  of  the 
cervix.     No  peri-uterine  alteration. 


Fig.  276.— Eetroflexion  in  the 
third  degree,  without  hy- 
pertrophy: projecting  spur. 
Muco-purulent  uterine  leu- 
corrhoea. 


Fig.  277.— Eetroflexion  in  the  first  degree 
with  retroversion. — c,  contraction  and 
depression  of  the  circular  os ;  A,  pos- 
terior neo-memhranous  utero-perito- 
neal  adhesions. 


piagnosis— subjective  signs. — It  is  difficult  to  decide  as  to  the 
existence  of  a  flexion  from  subjective  phenomena  alone,  but  not  im- 
possible. Evidently  there  are  flexions  which  pass  unnoticed,  especially 
before  puberty  or  marriage,  in  old  age,  or  in  a  very  large  pelvis ;  but 


FLEXIONS 


417 


the  majority  give  rise  to  symptoms  more  or  less  marked  in  proportion 
to  the  sensitiveness  of  the  patient,  the  narrowness  of  the  pelvis,  and 
the  pathological  nature  and  degree  of  the  flexion. 


Fig.  278. — Retroflexion  in  the  third  degree,  general  hypertrophy  of  the  uterus 
and  partial  hypertrophy  of  the  posterior  lip.  o,  descent  of  the  right 
ovary ;  Ai,  adenitis  and  retro-uterine  and  latero-uterine  inflammatory  in- 
duration ;  u,  projection  of  the  fundus  against  the  anterior  wall  of  the 
rectum  and  the  posterior  wall  of  the  vagina. 

Amongst  the  common  symptoms  which  have  seemed  to  me  the  most 
frequent  in  flexions,  as  well  as  the  most  distinctive,  are  the  following : 
purely  mechanical  dysmenorrhoea,  sometimes  shght,  at  other  times 
excessive,  the  escape  of  the  blood,  especially  of  the  first  drops,  being 
preceded  and  accompanied  at  every  menstruation  with  violent  uterine 
colics ;  menorrhagia,  the  difficulty  of  the  sanguineous  evacuation  in- 
creasing the  congestion,  and  the  latter  in  its  turn  provoking  haemor- 
rhage, the  intensity  and  duration  of  which  is  sometimes  alarming; 
pain  in  coitus,  especially  in  cases  of  retroflexion  complicated  with 
uterine  congestion,  metritis,  perimetritis,  peritoneal  adhesions,  &c. 
Sterility  is  frequent,^  though  by  no  means  a  necessary  consequence  of 

'  According  to  Sims  (op.  cit.,  237),  two  thirds  of  sterile  women  are  affected 
with  flexions  or  versions,  the  deviations  forwards  being  more  numerous  in 
women  whose  sterility  is  natural,  deviations  backwards  in  women  whose  sterility 
is  acquired. 

27 


418  UTERINE    DISEASES    IN    DETAIL 

flexions,  for  I  have  known  women  with  flexions  become  pregnant ; 
in  some,  gestation  rectifies  the  displacement,  whilst  in  others  it  aggra- 
vates it,  especially  in  the  case  of  retroflexion.     Leucorrhoea  also  often 


Fig.  279. — Diagnosis  of  retroflexion  by  the  touch. 

accompanies  it  and  makes  the  flexion  more  painful,  while  it  is  made 
more  persistent  by  the  flexion  which  renders  the  discharge  of  the  leu- 
corrhceal  mucus  more  difficult.  I  have  had  patients  affected  with 
flexions  in  whom  leucorrhoea  was  the  only  subjective  symptom,  and 
who  were  cured  of  the  leucorrhoea  as  well  as  of  the  flexion  by  repeated 
cauterisations  of  the  uterine  cavity  after  temporary  replacement  of  the 
uterus. — Vesical  and  rectal  disorders  result  from  the  pressure  exercised 
on  the  bladder  or  rectum. — The  weight,  the  dull  pelvic  pain,  the 
lumbar  dragging,  are  increased  by  walking  and  condemn  a  number  of 
patients  to  absolute  rest;  I  have  known  several  who  for  ten  or  fifteen 
years  were  constantly  confined  to  the  sofa;  in  such  cases,  however, 
the  symptoms  of  engorgement,  congestion,  metritis,  and  other  organic 
alterations  were  so  mingled  with  those  of  flexion  as  to  make  all 
differential  diagnosis  impossible. 

Objective  signs. — Vaginal  and  rectal  touch  associated  with  palpation 
usually  suffice,  except  in  very  stout  women,  to  allow  of  the  uterus  being 
seized,  to  determine  the  absence  of  the  body  above  the  isthmus  and 
to  give  an  idea  of  the  new  form  and  of  the  degree  of  inclination  of 


FLEXIONS 


419 


the  organ.  Whilst  the  hand  pressed  on  the  hypogastrium  cannot  find 
the  body  of  the  uterus  on  a  level  with  the  brim,  as  in  the  normal  con- 
dition, the  finger  introduced  into  the  vagina  feels  a  solid  round  tumour 
behind  or  in  front  of  the  neck  and  projecting  beyond  it,  which  is  the 
uterine  fundus,  but  which  may  be  mistaken  for  the  pregnant  womb  or 
for  a  fibroid. 

The  speculum  is  of  little  use,  except  in  cases  of  flexion  of  the  neck, 
where  examination  by  means  of  Sims's  speculum  decides  the  degree  of 
the  flexion,  the  form,  position  and  dimensions  of  the  orifice,  as  well  as  the 


Fig.  280. — Diagnosis  and  reduction  of  retroflexion  by  the  sound. 

various  complications,  the  coexistence  of  which  it  is  so  important  to 
know  in  order  to  establish  the  indications  of  treatment.  As  to  the 
use  of  the  sound,  in  spite  of  what  Scanzoni^  says,  it  is  indispensable, 
although  an  experienced  physician  can  diagnose  a  flexion  without  it. 
Not  only  is  it  the  only  means  of  diagnosis  in  doubtful  cases,  but  it 
enlightens  us  as  to  the  direction,  seat,  degree  and  reducibility  of  the 
flexion,  the  absence  of  peritoneal  adhesions,  the  coexistence  of  a  torsion 
of  the  body  on  the  neck,  the  irritability  of  the  mucous  membrane  and 
of  the  OS  internum,  the  coexistence  of  endometritis,  &c.  I  have  seen 
errors  of  diagnosis  because  this  means  had  been  neglected.  Some 
patients  are  so  sensitive  as  to  necessitate  the  administration  of  chloro- 
form before  having  recourse  to  this  means  of  investigation. 

Treatment. — Slight  flexions  without  complications  are  not  serious, 

'  Op.  v\i.,  p.  29. 


420  UTERINE    DISEASES    IN    DETAIL 

and  anteflexion  less  so  than  retroflexion.  Flexions  complicated  either 
bj  metritis  or  by  peritoneal  adhesions  are  very  serious.  In  such  cases 
they  not  only  almost  always  produce  sterility  but  may  confine  the 
patient  to  bed  or  to  the  sofa.  Therefore,  in  spite  of  the  insufl&ciency  of 
our  means  of  treatment,  flexions  should  be  submitted  to  a  rational 
treatment,  in  the  treble  view  of  destroying  complications,  rendering 
them  tolerable,  and  of  favouring  the  natural  processes  which,  in  the 
majority  of  painful  flexions,  give  us  reason  to  trust  in  the  continuity 
of  the  reduction  and  the  permanence  of  cure. 

The  first  indication  to  fulfil  consists  in  subduing  the  complications 
and  reducing  the  flexion  to  its  greatest  degree  of  simplicity;  very 
often  the  complications  and  the  flexion  must  be  treated  alternately 
and  almost  simultaneously.  From  this  point  of  view  it  is  evident  that 
we  have  but  a  feeble  influence  on  complications  such  as  long-standing 
peritoneal  adhesions ;  whilst,  on  the  contrary,  we  can  get  a  consider- 
able hold  upon  uterine  and  peri-uterine  inflammation,  upon  congestion, 
engorgement,  and  the  tumefaction  and  softening  which  characterise 
defective  retrograde  evolution  after  labour ;  but  even  as  to  the  former, 
we  must  never  despair  of  modifying  them,  nor  of  obtaining  a  cure  in 
the  course  of  time  from  therapeutic  agency  and  from  the  favorable 
intervention  of  physiological  function.  For  instance,  a  pregnancy  may 
occur  and  overcome  adhesions  which  have  seemed  incurable.  Anti- 
phlogistics,  resolvents  in  the  form  of  rectal  injections  of  an  iodide 
solution,  or  of  mercurial  ointment,  purgatives,  repeated  laxatives, 
blisters,  alteratives,  various  mineral  waters,  or  hydropathy,  may, 
according  to  the  case,  fulfil  this  first  indication.  Sometimes  we  must 
limit  ourselves  to  the  use  of  these  means  and  to  supporting  the  uterus 
and  perinseum  by  a  hypogastric  belt  or  perinseal  bandage.  When,  on 
the  contrary,  these  complications  do  not  exist  or  when  they  have  dis- 
appeared the  flexion  may  be  acted  on  directly. 

Eeduction  and  retention  are  effected  by  local  means  aided  by  general 
treatment  which  we  shall  review. 

I.  In  reducing  flexions  we  make  use  of  the  hands  or  of  the  sound, 
or  of  both.  The  hand  can  effect  little  in  the  case  of  anteflexion  ;  but 
in  retroflexion,  one  or  two  fingers  introduced  into  the  vagina  or  rectum 
can,  by  pushing  the  fundus  towards  the  brim  (while  the  genupectoral 
attitude  is  assumed),  easily  manage  to  restore  the  longitudinal  axis  of 
the  uterus  to  its  normal  direction,  even  in  cases  of  pregnancy,  unless  the 
organ  be  wedged  into  the  pelvis.  I  have  recently  reduced  a  retro- 
flexion in  a  pregnant  woman  in  the  fourth  month ;  the  body  of  the 
uterus  was  fixed  in  the  cavity ;  the  cervix,  though  not  deviated, 
seemed  to  have  descended,  and  its  anterior  segment  compressed  the 
urethral  canal,  causing  retention  of  urine  for  forty-eight  hours  ;  after 
having  catheterised  with  difficulty,  and  having  drawn  four  quarts  of 
urine,  I  succeeded  in  replacing  the  organ. 

The  use  of  the  sound  is  indispensable  except  in  cases  of  possible 
pregnancy ;  it  should  be  introduced  with  great  caution  for  fear  of 
perforating  the  softened  uterus ;  but  without  this  instrument  reduction 
would  sometimes  be  impossible.     After  having  penetrated  into  the 


FLEXIONS  421 

cervix,  we  try  to  pass  the  contraction  corresponding  to  the  seat  of  the 
flexion^  taking  care  to  turn  the  curve  of  the  sound  to  the  side  of  the 
uterine  curve,  and  only  to  depress  or  raise  the  handle  of  the  instrument 
in  proportion  as  the  point  penetrates  without  resistance,  and  as  much 
as  possible  without  pain,  into  the  cavity  of  the  body,  after  which  by 
giving  a  different  direction  to  the  handle  and  turning  the  curve  of  the 
instrument  in  an  opposite  direction  from  that  of  the  flexion  the  organ 
may  be  gradually  straightened.  In  cases  where  excessive  softening 
of  the  uterine  tissue  or  the  resistance  of  recent  peritoneal  adhesions 
are  to  be  feared,  the  use  of  the  sound  should  be  associated  with  hypo- 
gastric palpation,  or  with  the  catheter  in  anteflexion,  and  vaginal  or 
rectal  touch  in  retroflexion. 

II.  To  maintain  reduction  mechanical  means  may  be  used,  or  means 
intended  to  modify  the  vitality  and  texture  of  the  uterus. 

1.  Mechanical  means  may  be  divided  into  two  classes  according  to 
whether  they  are  applied  externally  or  internally. 

The  external  or  extra-uterine  means  are  :  tampons  introduced  into 
the  rectum  above  the  sphincter  as  proposed  by  Huguieri  for  retro- 
flexion ;  often  too  painful  to  be  borne.  A  tampon  of  cotton  saturated 
with  glycerine  applied  either  behind  the  cervix  or  before  and  below  it 
after  reduction.  Vaginal  pessaries,  whether  free  or  retained,  ought 
always  to  be  much  more  raised  on  one  side  than  on  the  other  so  as  to 
prevent  the  descent  of  the  fundus  before  or  behind,  according  to  the 
side  on  which  this  eminence  is  placed,  and  so  maintain  the  reduction  : 
amongst  these  pessaries  the  best  are  the  triangular  pessary  of  Simpson 
and  Priestley,  Simpson's  stem  pessary,  that  of  Kennedy  (of  Liverpool), 
which  is^copied  from  that  of  Hervez  de  Chegoin.  Sponges  or  pessa- 
ries (those  of  Hodge  or  Graily  Hewitt)  pushing  back  the  cervix,  so 
as  to  prevent  this  organ  from  resuming  its  false  position  and  the  body 
from  falling  forwards  again.  Lastly,  hypogastric  or  pelvic  belts  either 
simple  or  with  an  anterior  or  posterior  plate,  alone  or  associated  with 
a  pad  and  perinseal  bandage ;  or  the  latter  bandage  may  be  used  alone 
in  cases  where  hypogastric  pressure  cannot  be  borne.  It  is  very 
seldom  that  the  hypogastric  belt  is  not  useful  in  cases  of  anteflexion  ; 
but  it  is  painful  and  often  intolerable  in  retroflexion ;  the  perinoeal 
pad,  on  the  contrary,  alone  or  supporting  a  tampon  saturated 
with  glycerine  or  an  air  pessary  with  unequal  borders  is  of  great 
service. 

Intra-uterine  pessaries^  recommended   by  Simpson,   Kiwisch    and 

'  See  p.  192. 

^  The  use  of  intra-uterine  stems  or  the  mechanical  treatment  of  flexions  is 
recommended  in  Germany  by  Martin  (Die  Neigungen  und  Beugungcn  des 
Uterus.  Berlin,  1870),  Winkel  {Bchandlung  der  Flexionen  des  Uterus  mit 
intra-uterinen  Elevatoren,  1872),  Schultze  {Archiv  f.  GynaeJcologie,  Bd.  iv, 
1872),  Amann  {Zur  mechanisch.  Beliandlung  der  Versionenund  Flexionen  des 
Uterus.  Munich,  1874),  Schroder  {Handhuch  der  A'ranlcheiten  der  weiblichen 
Geschlectsorgane,  1874)  ;  in  Sweden  hy  Eklund  {De  I'Etiolog.  et  du  trait,  des 
retrof.  utcr.  Stoclvholm,  1875)  ;  in  England  by  G.  Hewitt  {Obstetric.  Transact., 
vol.  X,  18G9),  Williams  (Ibid._,  1874),  Barnes  {Diseases  of  Women,  1876)  ;  in 
America  by  Thomas  {Practical  Treatise  of  Diseases  of  Women,   1876)  ;  in 


422 


UTERINE    DISEASES    IN    DETAIL 


Valleix  have  been  long  abandoned  in  France.  I '  am  as  ready  as  any 
one  to  admit  the  danger  of  intra-uterine  pessaries  in  some  cases.  I 
have  seen  a  patient^  who  seemed  to  tolerate  one  of  these  stems  for 
twenty-four  hours,  die  of  metro-peritonitis  in  spite  of  the  most  ener- 
getic and  judicious  antiphlogistic  treatment.  Patients  have  returned 
to  me  from  Valleix  uncured  of  their  maladies,  whom  he  thought  were 
cured,  as  Kiwisch's  patients  went  to  Scanzoni.  Nevertheless,  I  am 
more  than  ever  convinced  that  the  use  of  such  instruments  should  not 
be  proscribed.  Their  action  is  not  merely  mechanical;  it  excites 
uterine  contractility  owing  to  the  natural  reaction  of  any  physical  im- 
pression on  our  organs.  This  excitement,  however,  becomes  injurious 
when  great  irritability  disposes  the  uterus  to  become  inflamed,  or  when 
inflammation  has  already  attacked  it  or  the  neigbouring  organs.  There- 
fore uterine  or  peri-uterine  inflammation  is  always  a  contraindication 
to  their  use. 

In  cases  where  these  contraindications  do  not  exist  these  stems  may 
be  used,  but  loose  means  of  retention  should  always  be  preferred  to 
those  of  absolute  immobilisation,  which  unfortunately  were  formerly 
used.  The  stem,  whilst  keeping  both  parts  of  the  uterus  straightened, 
and  being  itself  held  sufiiciently  in  place  by  its  bulb  and  a  tampon 
saturated  with  glycerine,  should  be  left  at  liberty  to  oscillate  in  various 
directions  with  the  womb  according  to  the  movements  of  the  patient, 
instead  of  exposing  the  uterus  to  injury  from  every  movement  of  the 
body,  as  would  be  the  case  were  the  stem  immovably  fixed. 

I  have  used  this  means  of  treatment  in  retro- 
flexion since  the  stem  was  first  introduced  into 
Prance,  and  have  found  it  most  successful  when 
the  uterus  is  too  flexible  to  be  retained  in  po- 
sition by  any  other  means. 

In  describing  the  treatment  of  each  special 
flexion  we  shall  determine  what  agents  of  re- 
duction and  retention  should  be  specially  em- 
ployed. 

2.  The  local  and  general  modifications  suit- 
able for  favouring  and  maintaining  retention 
are  :  posture,  hydropathy,  tonics,  ergot,  elec- 
tricity, cauterisation,  &c. 

Posture  is  important  especially  in  recent 
flexions  :  it  allows  the  tumefaction  of  the  organ 
to  subside,  it  prevents  congestion  from  increas- 
ing, it  helps  resolution,  it  prevents  the  for- 
mation of  vicious  adhesions. 

In  cases  of  anteflexion  patients  should  lie  on 

the  back,  with  the  pelvis  raised  and  the  limbs 

flexed.     In  retroflexion  they  should  lie  on  the  stomach. — Hydropathy, 

general  rather  than  local,   or  as  regards  the  latter  cold  sitz-baths, 

vaginal  irrigations,  the  douche  on  the  loins  and  sides,  will  aid  in 

Russia  by  Tarnowsky  (M^  Gontcharoff ,  Flexions  uterines  au  point  de  vue  de 
leur  traitement.  Paris,  1877),  &c. 


Fig.  281.  —  Galvanic 
stem  kept  in  place 
by  a  tampon  satu- 
rated with  glyce- 
rine in  a  retroflexed 
uterus  previously 
reduced. 


f^LEXIONS  423 

raising  the  tone  of  the  organ  and  in  exciting  uterine  contractility. — 
Tonics,  including  iron,  mineral  waters  such  as  those  of  Lamalon,  sea 
bathing,  &c.,  act  in  the  same  direction  as  hydropathy. 

There  are,  however,  three  local  modifications  superior  to  the  pre- 
ceding if  they  answer  to  all  that  they  appear  to  promise  j  these  are, 
ergot,  electricity  and  cauterisation. — Ergot  is  an  excellent  means  of 
stimulating  the  contractility  of  the  uterus  when  defective,  especially 
in  retroflexion.  This  repeated  provocation  of  muscular  contraction 
excites  a  hypertrophic  tendency  in  this  tissue,  which  is  very  useful  in 
overcoming  the  atrophy  which  has  its  seat  at  the  point  of  flexion  and 
in  all  the  corresponding  wall.  Considerable  results  are  obtained  by 
giving  three  or  four  grains  every  day  for  a  month,  resting  at  the 
monthly  period. — Electricity  has  been  employed  by  Fano^  to  give 
contractile  power  to  the  side  of  the  uterus  opposite  the  angle  of  flexion, 
sufficient  to  shorten  the  fibres  and  so  straighten  the  uterus.  It  is 
evident  that  the  action  of  electricity  in  this  case  may  also  aff'ect  the 
superficial  muscular  layer  extending  into  the  broad,  utero-lumbar  and 
utero-pubic  ligaments.  One  of  the  poles  should  be  placed  on  the 
cervix  or  in  the  uterine  cavity  or  on  the  lip  of  the  cervix  corresponding 
to  the  side  of  the  womb  opposite  the  angle  of  flexion,  the  other  pole 
on  the  hypogastrium,  the  inguinal  regions,  sides  or  loins,  according  to 
the  direction  of  the  curve.  In  some  cases  this  means  seems  to  me 
to  have  helped  the  others. — Cauterisation,  especially  when  deep,  so  as 
to  destroy  a  part  of  the  cervical  tissue,  as  recommended  by  Grenet,^ 
may  in  some  cases  be  most  useful. 

Following  the  example  of  Amussat  and  Bonnet,  since  1852  I  have 
cauterised  the  neck  very  high  up,  as  well  as  the  vagino-uterine  cul-de- 
sac  on  the  side  opposite  the  deviation,  not  only  in  versions  but  in 
flexions.  This  operation  has  been  so  successful  with  me  that  I  have 
not  feared  to  repeat  it  several  times  in  the  same  patient.  As  for  flexions 
in  particular,  while  accepting  Grenet's  explanation  that  cauterisation 
produces  a  cicatricial  tissue  which  shortens  the  fibres  on  the  side  of  the 
uterus  to  which  it  is  applied,  not  forgetting  the  modification  which 
this  operation  never  fails  to  effect  in  the  uterine  tissue,  and  which 
manifests  itself  by  a  great  tendency  to  resolution  of  the  engorged  parts, 
I  think  that  even  deep  cauterisation  of  the  cervix  on  a  level  with  the 
cul-de-sac  of  the  side  opposite  the  flexion  is  especially  useful  in  flexion 
of  the  cervix,  less  so  in  that  of  the  isthmus,  and  still  less  in  that  of 
the  body. 

2.  Flexions  in  particular 

By  proceeding  to  an  analytical  study  of  each  flexion  the  differences 
in  the  nature,  characters,  symptoms  and  treatment  of  each  can  be 
brought  into  relief.  In  the  first  place  we  observe  that  flexions  are  not 
indifferent,  there  being  some  which  cause  great  suffering  in  the  absence 
of  all  complications. — We  also  discover  that  there  are  special  symptoms 

^  Union  medicale,  1859,  and  Vidal  de  Cassis,  Pathologie  externe,  v,  384 
Paris,  1861. 

^  Gazette  des  hojpitaux,  Nos.  54  to  58,  May,  1865. 


424  UTERINE    DISEASES    IN    DETAIL 

characteristic  of  each  kind  of  flexion  sufficient  to  lead  us  to  suspect  if 
not  to  diagnose  it.  It  is  not  only  the  direction  of  the  flexion  which 
varies,  but  the  cause  and  the  nature  of  the  alterations  which  produce 
the  change  in  the  form  of  the  uterus  in  both  cases.  We  therefore 
naturally  conclude  that  the  treatment  of  these  flexions  ought  to  differ 
according  to  the  nature  which  characterises  the  fundamental  alterations 
in  each.  This  treatment,  in  place  of  being  merely  palliative,  is  in 
many  cases  curative,  and  being  founded  on  real  knowledge  of  the  ana- 
tomical nature  of  the  malady,  when  wisely  applied  never  fails  to  give 
real  relief  proportioned  to  the  extent  of  the  reduction  and  the  perma- 
nence of  the  retention.  Emmet,  in  a  recent  paper,i  gives  the  statistics 
of  all  the  cases  he  has  had.  In  345  flexions  there  were  182  of  the 
cervix,  the  others  of  the  body,  which  gives  53  per  cent,  for  flexions 
of  the  cervix,  47  per  cent,  for  the  body ;  and  among  the  latter  he 
counted  91  anteflexions  or  56  per  cent.,  39  retroflexions  or  18  per 
cent,  (one  third  anteflexions,  whilst  as  regards  versions,  retroversion  is 
as  frequent  as  anteversion),  43  latero- flexions  or  26  per  cent,  (which 
seems  to  me  an  exaggeration),  twice  as  many  to  the  left  as  to  the 
right.  • 

"  a.  Flexions  of  the  Cervix 

These  are  rarely  found  in  women  who  have  been  pregnant,  but  often 
in  girls,  especially  at  puberty.  Dysmenorrhoea  and  sterility  reveal  their 
existence :  the  duration  of  menstruation  in  such  cases  would  be  less 
than  the  average.  The  medium  age  of  those  affected  is  twenty-five 
years,  which  is  earlier  than  that  of  other  flexions. 

They  seem  to  originate  at  puberty  from  unequal  development  of  the 
body  and  neck.  When  the  body  is  anteverted,  which  is  to  some  extent 
the  normal  congenital  position,  the  neck  cannot  be  considerably  de- 
veloped in  length  without  meeting  the  posterior  vaginal  wall  which 
deviates  it,  flexes  it,  and  forces  it  to  develop  itself  in  the  direction 
which  offers  the  least  resistance,  i.  e.  in  the  axis  of  the  vagina,  and 
as  this  axis  forms  an  open  angle  in  front  with  the  axis  of  the  uterus, 
especially  when  this  organ  is  curved  forwards,  anteflexion  of  the 
cervix  necessarily  follows.  Such,  according  to  Emmet,  is  the  cause 
of  flexions  of  the  cervix  and  of  their  frequency ;  it  will  be  seen  that 
this  flexion  is  only  the  consequence  of  flexion  of  the  body  in  the 
same  direction  which  gives  the  horse-shoe  form  to  the  uterus.  This 
continuity  between  the  curve  of  the  body  and  that  of  the  neck  is 
probably'the  reason  why  other  gynecologists  have  not  given  the  same 
importance  to  flexions  of  the  cervix,  some  attributing  to  the  uterus 
as  a  whole  the  flexion  seated  in  the  supra-vaginal  portion  of  the 
cervix,  others  forgetting  that  when  the  direction  of  the  cervix  is  the 
same  as  that  of  the  vaginal  axis,  it  necessarily  follows  that  this  organ 
is  flexed  forwards,  since  its  orifice  ought  normally  to  look  towards 
the  posterior  vaginal  wall.     There  are  certainly  a  great  many  cases 

'  The  etiology  of  uterine  flexures,  with  proper  mode  of  treatment  indicated, 
Transactions  of  the  American  Gynecological  Society,  p.  48,  vol.  i.    Boston, 

1877. 


FLEXIONS  425 

described  and  treated  as  mechanical  dysmenorrhoea  which  ought  to 
have  been  classed  as  flexions  of  the  cervix  :    the  only  question  is  to 


Fig.  282, — Anteflexion  of  a  conical  cervix  with  narrow  os  (after  Barnes). 

determine  whether  this  alteration  in  the  form  of  the  neck  is  the 
dominant  element  of  this  complex  pathological  state,  or  if  it  is  not 
rather  the  congenitally  narrow  os,  the  contraction  of  the  sphincter, 
combined  with  retraction  of  the  fibres  of  the  anterior  segment,  which 
causes  the  inequality  between  the  two  walls  and  the  curvature  with 
the  anterior^  concavity,  so  well  understood  by  Cusco.  It  is  certain 
that  analogous  means  of  treatment  are  applied  to  the  malady  described  , 
in  most  gynecological  works  as  mechanical  dysmenorrhoea,  as  in 
Emmet's  paper  to  flexion  of  the  cervix,  and  there  is  no  doubt  that 
flexion  of  the  cervix  rarely  exists  without  narrow  and  conical  os,  ante- 
flexion of  the  body,  contraction  of  the  external  sphincter,  of  the 
muscular  fibres  of  the  anterior  segment  and  of  the  utero-sacral 
ligaments,  in  short,  without  the  concurrence  of  the  majority  of 
the  conditions  belonging  to  anteflexion,  and  especially  to  pathological 
anteflexion. 

Diagnosis. — Flexion  of  the  cervix,  easily  recognised  by  the  long 
neck  lying  in  the  axis  of  the  vagina,  is  seen  in  girls  at  puberty  or  in 
young  married  women,  accompanied  by  dysmenorrhoea  and  sterility 
and  often  by  anteflexion  of  the  body  and  elevation  of  the  organ. 
The  pain  shows  itself  chiefly  at  the  commencement  of  the  menstrual 
period  ;  it  is  less  severe  in  virgins  than  in  married  women  ;  in  the  latter 
it  is  accompanied  by  hypertrophy  and  diseases  of  the  body  in  addition 
to  anteflexion  of  the  latter.  If  conception  does  not  take  place  during 
the  first  year  of  married  life,  the  chances  of  its  occurring  later  are 
greatly  diminished,  flexion  always  having  a  tendency  to  increase,  as 


426 


UTERINE    DISEASES    IN    DETAIL 


well  as  the  complications  which  accompany  it,  anteflexion  of  the 
body,  diseases  of  this  organ,  the  transmission  of  irritation  to  the 
ovary,  &c. 

The  treatment  is  exclusively  surgical.  We  must,  however,  assure 
ourselves  beforehand  that  there  is  neither  uterine  nor  peri-uterine  inflam- 
mation. After  all  it  is  not  very  often  indicated ;  for  Emmet  admits 
that  he  has  not  met  with  one  serious  enough  to  be  operated  on  more 
frequently  than  once  a  month. 

This  treatment  consists  in  the  division  of  the  cervix  proposed  by  Simp  • 
son,  performed  by  him  on  the  lateral  parts  of  the  orifice,  by  Marion  Sims 
on  the  posterior  lip  by  means  of  his  bistoury  with  a  short  revolving 
blade,  and  by  Emmet  on  the  same  lip  (median  incision),  but  by  means 
of  strong  bent  scissors,  which  operate  more  quickly  and  are  less  apt 
to  cause  hsemorrhage  than  the  bistoury.  After  having  made  the 
median  incision,  the  borders  may  be  rounded  so  as  to  form  a  concave 
opening  of  the  whole,  at  the  base  of  which  if  necessary  the  canal 
may  be  divided  by  means  of  the  bistoury,  or  it  may  be  dilated  by 


Tig.  283. — Median  incision  of  the  posterior  lip,  treatment  of  flexion  of  the 
cervix  ;  s,  speculum  ;  tr,  uterus  ;  a,  anterior  lip  ;  p,  posterior  lip  ;  e,  tena- 
culum hook  inserted  into  the  anterior  lip  to  draw  the  utems  near  the 
operator ;  c,  scissors  to  divide  the  posterior  lip  p. 

the  repeated  introduction  of  sponge  tents  of  increasing  size,  a 
method  of  treatment  which  rectifies  and  widens  the  cervico-uterine 
canal  sufficiently  to  cure  dysmenorrhcea  and  to  facilitate  conception, 
especially  if  coitus,  in  place  of  being  performed  in  the  ordinary  way  is 
performed  more  bestiarum ;  in  this  posture  the  penis  and  semen  are 
more  sure  of  reaching  the  posterior  utero-vaginal  cul-de-sac  on  a  level 
with  the  opening  made  in  the  posterior  lip  by  median  incision,  resec- 
tion of  the  angles  and  borders,  and  dilatation  of  the  rest  of  the  canal. 
Sometimes,  as  seen  in  Figs.  284  and  285,  a  portion  of  the  too  long 
posterior  lip  should  be  excised  (Eig.  284,1)  after  making  the  median 
excision  of  this  lip  (Fig.  285,  2),  which  is  the  only  way  of  ensuring 
the  direct  penetration  of  the  semen  into  the  uterine  cavity.     It  will 


FLEXIONS  427 


be  seen  that  the  operation  has  to  be  varied  according  to  the  extent 
of  the  flexion,  the  degree  of  the  curve,  the  length  and  volume  of  the 


Fig.  284.— 1.  Portion  of  the  pes-  Fi&.  285.-2.  Poi-tion  o£  the  pos- 
terior lip  which  is  excised  tenor  lip  to  be  divided  in 
in  case  of  extreme  flexion  of  the  centre  after  excision  of 
the  cervix.  portion  1. 

flexed  portion,  and  the  complications,  such  as  tumours,  &c.  When, 
however,  the  principle  is  understood,  it  is  easy  to  apply  it  to  individual 
cases. 

h.  Antejiexions  of  the  Body 

Anteflexion  may  be  either  congenital  or  acquired,  limited  to  a 
segment  of  the  body  of  the  organ  or  extended  to  the  neighbouring 
parts,  and  particularly  to  the  suspensory  ligaments. 

a.  Congenital  physiological  anteflexion. — This  is  an  exaggeration  of 
the  usual  conditions  of  form  and  inclination  of  the  uterus  in  the 
foetus,  in  the  child  and  young  girl  at  puberty,  often  even  in  the  adult 
nullipara.  If  the  relative  excess  of  increase  which  the  anterior  seg- 
ment should  take  at  puberty  to  compensate  for  its  original  shortness 
does  not  occur  the  temporary  congenital  anteflexion  may  become  a 
permanent  one :  in  this  case  it  may  be  said  to  be  due  to  imperfect  deve- 
lopment of  the  anterior  wall.  At  other  times,  in  place  of  being  deve- 
loped this  wall  atrophies,  thereby  exaggerating  the  anteflexion  in  place 
of  correcting  it.  At  other  times  the  production  of  this  physiological 
anteflexion  is  much  more  complicated :  under  the  influence  of  the 
irritation  which  congenital  anteflexion  produces  in  the  organ,  of  the 
obstacle  placed  in  the  way  of  the  accomplishment  of  the  functions, 
especially  of  menstruation,  &c.,  contraction  is  produced  in  the  unstriped 
muscular  fibres  of  this  segment  of  the  uterus,  shortening  them  and 
finally  causing  retraction,  not  only  in  the  fibres  of  the  organ  but  in 
those  arising  from  it  which  are  inserted  into  the  sacro-lumbar  verte- 
bra; this  produces  a  direct  exaggeration  of  the  anteriorly  concave 
curve,  and  an  indirect  increase  of  this  same  curve  by  bringing  the 
upper  portion  of  the  neck  nearer  the  sacro-vertebral  angle,  and  conse- 
quently a  more  marked  aggravation  of  an  anteflexion  originally  con- 
genital, produced  in  fact  by  a  purely  physiological  cause. 


428 


UTBEINE    DISEASES    IN    DETAIL 


I.  Pathological  anteflexion . — This  is  the  name  given  by  Schnitzel 
to  acquired  anteflexion ;  it  may  be  produced  by  several  causes,  for  if 


Fia  286. 


-Usual  anteflexion  of  tlie  uterus  in  the  fcetus  and  child,  origin  of 
congenital  physiological  anteflexion  (after  Boullard). 


it  always  arises  more  or  less  from  peri-uterine  inflammation,  it  is  by 
various  consecutive  phenomena  that  it  does  so.  Sometimes  it  is  pro- 
duced directly  from  peri-uterine  inflammation  or  true  peritonitis,  by 
the  formation  of  false  membranes  uniting  the  fundus  of  the  bladder  to 
that  of  the  uterus,  the  posterior  surface  of  the  one  with  the  anterior 
surface  of  the  other.  Sometimes  it  is  produced  indirectly,  the  peri- 
uterine inflammation  having  its  seat  in  the  peritoneum  or  in  the  con- 
nective tissue  lining  it ;  it  is  then  propagated  to  Douglas's  ligaments, 
and  even  where  these  ligaments  are  cured  as  well  as  the  cellular  tissue 
and  surface  of  the  pelvic  peritoneum  there  still  remains  a  cicatricial 
retraction,  or  at  least  a  contraction  and  shortening  of  these  ligaments, 
bringing  the  cervico -uterine  isthmus  near  the  promontory  and  anterior 
surface  of  the  sacrum.  This,  however,  cannot  be  efl'ected  without 
raising  the  isthmus  and  removing  it  from  the  fundus  and  cervix,  with- 
out making  the  organ  project  behind  on  a  level  with  the  isthmus  while 
concave  in  front,  especially  if  the  fundus  is  retained  by  vesical  adhe- 
sions and  the  neck  by  a  hypertrophy  frequently  co -existing  with  these 
alterations.  This  anteflexion,  which  is  rightly  called  pathological,  is 
still  less  reducible  than  the  former,  but  it  is  characterised  by  histolo- 
gical alterations  of  the  same  nature,  contraction,  retraction  of  the 
suspensory  ligaments  and  induration  of  the  uterus  itself:  partial 
retraction  of  the  broad  ligaments  may  even  be  added,  inclining  the 
fundus  forwards,  whilst  the  isthmus  is  raised  behind ;  there  may  also 

•  Zur  Trage  von  der  pathologischen  Anteflexionen  der  Gebarmutter,  Archiv 
fur  Gynehol,  Bd.  ix,  S.  453.  Berlin,  1875. 


FLEXIONS 


429 


be  modular  retraction  of  the  connective  tissue  as  a  consequence  of 
cellulitis,  in  addition  to  the  contraction  of  the  suspensory  and  broad 


Fig.  287. — Pathological  anteflexion :  shortening  o£  ligaments  of  Douglas, 
ascent  of  the  cervix,  pressure  of  the  fundus  on  the  posterior  wall  of  the 
bladder. 

ligaments  and  tending  to  flex,  contract  and  indurate  the  organ  by  curv- 
ing it  forwards  on  itself. 

Treatment. — The  chief  indications  are  to  subdue  the  inflammation 
and  then  treat  the  consequences,  especially  muscular  contraction,  for 
this  contraction  is  the  principal  element  of  the  malady.  Prolonged 
general  baths  either  emolhent  or  alkaline,  with  vaginal  injections  all 
the  time,  Yichy  waters  externally  and  internally,  followed  by  hydro- 
pathy, repeated  mild  laxatives,  constant  poultices  on  the  abdomen 
covered  with  oil  silk,  resolvent  rectal  injections  of  mercury  and  bella- 
donna ointment,  followed  by  small  enemata  of  iodide  of  potassium, 
bromide  in  large  doses  internally,  sponge  tents  covered  with  belladonna 
ointment,  kept  in  place  by  tampons  saturated  with  glycerine  to  moisten 
the  mucous  membrane,  cause  an  abundant  secretion,  and  soften  the 
uterine  tissue ;  such  are  the  chief  means  employed  to  fulfil  the 
indications  :  antiphlogistics,  resolvents,  antispasmodics,  laxatives. 
When  we  have  to  do  with  hard  and  contracted  tissues,  we  must  have 
recourse  to  all  that  can  soften  and  dilate  them ;  these  are  not  the 
cases  for  intra-uterine  stems,  hardly  even  for  sponge  tents ;  but  the 


430  UTBEINE    DISEASES    IN    DETAIL 

belladonna  with  which  they  are  covered  and  the  glycerine  that  is 
added,  by  dilating  the  cervico-uterine  canal  and  softening  the  tissues, 
greatly  compensate  for  the  irritation  and  contractility  produced. 

Lastly,  patients  are  often  relieved  and  walking  is  facilitated  by  the 
use  of  hypogastric  belts  (see  Pigs.  150,  151),  which  remove  the 
weight  of  the  abdominal  viscera  from  the  anteflexed  uterus. 

c.  Later o-flexions  of  the  Body 

These  can  only  arise  from  anteflexions,  by  limitation  of  the  spas- 
modic or  cicatricial  retraction  of  one  of  the  suspensory  or  broad  liga- 
ments or,  it  may  be,  one  of  the  round  ligaments.  It  is  hardly  possible 
to  approach  the  description  of  these  incurvations  without  entering  on 
the  field  of  hypothesis ;  in  fact  everything  is  hypothetical  with  regard 
to  them.  The  cause  which  produces  them  as  well  as  the  seat  of  the 
pathological  alterations,  the  very  existence  indeed  of  latero-flexion,  is 
doubtful.  Latero-version  is  comprehensible,  but  latero-flexion  is  very 
different,  and  as  for  the  supposed  cases  which  have  occurred,  we  must 
remember  how  easy  it  is  to  confound  this  diagnosis  with  that  of  the 
uterus  unicornis,  which  has  sometimes  been  found  to  the  right  and 
sometimes  to  the  left  (see  Pig.  264).  If  such  a  case  really  occurred, 
as  the  cause  of  the  evil  must  have  its  seat  in  the  ligaments,  and  as 
this  cause  must  be  a  retraction,  either  congenital  or  consecutive  to  an 
inflammation  (for  a  softening  and  relaxation  of  the  tissues  could  not 
force  the  uterus  to  incline  in  one  direction  rather  than  another),  I 
would  institute  the  treatment  I  have  described  as  applicable  to  ante- 
flexion of  the  body. 

d.   Torsion  of  the  Uterus  on  itself,  and  Torsion  of  the  Body  on  the 

Neck 

The  cause  must  be  due  to  retraction  of  a  layer  of  oblique  fibres  of 
the  uterus,  or  of  ligamentary  fibres  variously  associated  together.  We 
have  seen  that  the  simultaneous  retraction  of  the  two  ligaments  of 
Douglas  consecutive  to  posterior  perimetritis  or  parametritis,  by 
raising  the  upper  portion  of  the  cervix  towards  the  sacrum,  produced 
an  anteflexion  (flexion  with  the  concavity  looking  forwards),  rightly 
called  pathological  by  Schultze.  It  is  evident  that  if  the  simulta- 
neous retraction  of  the  two  broad  ligaments  is  added  to  that  of  the 
utero-sacral  ligaments,  and  if  we  suppose  that  that  of  the  round  liga- 
ments is  also  associated,  the  fundus  of  the  organ  will  be  more  and 
more  inclined  forwards  and  the  flexion  increased.  If,  however,  only 
one  of  the  utero-sacral  is  retracted  anteflexion  will  be  more  marked  on 
one  side  than  on  the  other,  and  the  upper  part  of  the  neck,  whilst 
drawn  towards  the  sacrum  by  the  contracted  ligament  of  Douglas,  will 
also  be  more  drawn  towards  this  side  than  to  the  other,  giving  to  the 
neck  an  inclination  resulting  in  the  oblique  in  place  of  the  transverse 
direction  of  the  os.  If  the  broad  and  round  ligaments  of  the  opposite 
side  are  contracted  at  the  same  time,  this  rotation,  this  obliquity  of  the 
OS  uterinum,  this  torsion  of  the  whole  of  the  uterus  will  only  be  in- 
creased.    If,  on  the  contrary,  contraction  of  all  the  ligaments  takes 


FLEXIONS 


431 


place  on  the  same  side  there  will  be  no  longer  torsion,  inclination, 
obliquity,  but  latero-position  associated  with  anteflexion.  Lastly, 
whether  the  cervix  be  drawn  towards  the  sacrum  by  the  simultaneous 
contraction  of  both  utero- sacral  ligaments,  or  whether  only  one  of  the 
broad  or  round  ligaments  is  contracted,  there  will  be  torsion  of  the 
body  on  the  neck  at  the  isthmus,  torsion  which  in  certain  cases  will 
be  associated  with  that  already  produced  by  contraction  of  the  fibres, 
and  which  gives  an  oblique  direction  to  the  anterior  surface  of  the 
body  in  relation  to  that  of  the  neck  (see  Fig.  371,  p.  411). 

It  is  important  to  diagnose  these  torsions :  the  obliquity  of  the  os, 
the  difficulty  of  passing  the  sound,  the  inclination  (Pig.  270)  and 
spiral  movement  required  to  make  it  penetrate,  the  discovery  of  hard, 
stretched,  contracted  bundles  of  fibres  behind  or  at  the  sides  of  the 
uterus,  will  lead  to  a  diagnosis  and  to  a  suitable  treatment  being  in- 
stituted to  overcome  the  sterility,  which  is  the  usual  consequence  of 
these  torsions.  Treatment  is  the  same  as  for  anteflexion,  for  contrac- 
tion of  the  tissues  is  the  principal  element  in  both  cases.  Sometimes 
ignipuncture  may  be  indicated  on  a  limited  point  of  the  uterus  or  on 
the  fibrous  layer  adhering  to  it  and  containing  one  of  its  ligamentous 
bundles,  in  order  to  produce  a  limited  inflammation,  a  spasmodic 
contraction  of  this  bundle,  capable  of  counterbalancing  the  opposing 
contraction  which  contributes  most  to  produce  or  keep  up  the  torsion. 
Antiphlogistics,    resolvents    (alkaline    waters    and    hydropathy)    and 


Fig.  288.. 


-Retroflexion   in  the   first  degree  :  the  cervix  low,  the  fundus  above 
the  ligfinients  of  DoiiirUis. 


432 


UTEEINB    DISEASES   IN    DETAIL 


repeated  dilatations  with  sponge  tents  associated  with  belladonna  oint- 
ment, glycerine,  &c.,  are  the  principal  means  of  treatment. 

e.  Hetfofiexion  of  the  Uterus, 

We  now  enter  a  field  of  histological  alteration  totally  different,  if  not 
diametrically  opposed,  to  all  the  preceding.  Till  now,  the  only  direct 
agents  of  partial  deviations  and  incurvations  which  we  have  met  with  are 
retractions  of  tissue  and  shortening  of  the  muscular  fibres  and  liga- 
ments. We  shall  now  have  to  do  with  elongation,  distension,  softening 
and  rupture.  In  fact  retroflexion  is  in  every  respect  the  opposite  of 
anteflexion.  Not  only  is  the  organ  curved  in  a  different  direction  (the 
concavity  being  behind  in  place  of  in  front)  but  it  is  hardly  ever 
congenital,  but  always  developed  as  the  result  of  a  morbid  alteration, 
this  being  the  case  even  in  congenital  retroflexion  ;  retroversion  is  not 
uncommon  amongst  girls  and  nullipara ;  congenital  retroflexion,  on 


Fig.  289. — Eetroflexion  in  the  second  degree  :  the  cervix  low,  the  fundus  on  a 
level  with  the  ligaments  of  Douglas. 

the  other  hand,  is  exceedingly  rare  -^  the  acquired  form  is  very 
common  in  multiparse  and  is  almost  always  the  result  of  labour  or 
abortion ;  it  is  never  caused  by  contraction,  but  is  almost  always 

'  Grenser,  "  Die  Riickwartslagerungen  der  Gebarmutter  bei  Jungfrauen  und 
Nullipai'en,  nebst  Bemerkungen  zur  Retroflexio  uteri  congenitalis,"  in  Archiv 
f.  Gynaehol,  Bd.  xi,  Heft  1.     Berlin,  1877. 


FLEXIONS 


433 


characterised  by  thinness,  softening,  distension  and  even  rupture  of 
the  muscular  fibres  of  the  uterus  and  its  ligaments;  it  rarely  coincides 
with  elevation  of  the  womb,  usually  on  the  contrary  with  prolapsus ; 
the  fundus  reaches  a  much  greater  degree  of  prolapsus  behind  than 
that  which  it  acquires  in  front  in  anteflexion. 

There  are  at  least  three  degrees,  according  to  whether  the  fundus  is 
above,  on  a  level  with,  or  below  the  ligaments  of  Douglas  and  the  cer- 


FiG.  290. — Retroflexion  in  the  third  degi-ee  :  the  cervix  low  and  directed  for- 
wards, the  fundus  below  the  ligaments  of  Douglas. 

vix ;  in  the  first  degree  the  fundus  is  above  the  ligaments  of  Douglas 
and  the  cervix  ;  in  the  second  degree  it  is  on  a  level  with  them  ;  in  the 
third  degree  it  is  below,  and  the  whole  organ  is  at  the  same  time  more 
and  more  lowered  by  the  extension  and  distension  of  these  ligaments. 
The  day  after  delivery  when  the  previously  retroflexed  uterus  falls 
down  into  the  pouch  of  Douglas,  it  may  fall  so  low  as  to  be  felt  filling 
this  space  through  the  perinseum,  the  anus,  the  lower  part  of  the 
rectum  and  the  posterior  portion  of  the  vagina.  This  may  be  called  a 
fourth  degree  peculiar  to  the  puerperal  state. 

The  uterus  often  remains  prolapsed  and  retroflexed  for  a  long  time 
without  any  considerable  alteration  being  produced  in  its  tissue ;  but 
sometimes  alterations  are  manifested  very  early,  proving  the  necessity 
of  hastening  reduction  and  retention,  lest,  by  delaying  too  long,  they 

28 


434 


UTERINE    DISEASES    IN    DETAIL 


become  impossible.  In  Figs.  292  and  293  borrowed  from  Graily 
Hewitt,  retroflexion  in  the  second  degree  is  seen  in  which  the  cervico- 
uterine  canal  is  maintained  free  in  all  its  extent ;  and  a  retroflexion  in 
the  third  degree  where  the  canal  is  obstructed  at  one  point  by  the 


Fig.  291. — Retroflexion  in  tlie  puerperal  condition,  carried  to  a  still  higher 
degree,  the  cervix  being  low  and  directed  forwards,  the  fundus  resting  on 
the  floor  of  the  perinfeum  in  the  pouch  of  Douglas. 


Fig.  292. — Eetroflexion  in  the   second  degree,  with  persistence  of  the  corvico- 
nterine  canal  (after  Graily  Hewitt). 


FLEXIONS 


435 


meeting  of  the  two  walls.  Lastly,  in  the  preparation  represented  in 
l^ig.  294  of  long-standing  retroflexion  of  the  third  degree  is  seen  not 
only  the  occlusion  but  the  obliteration  of  the  cavity,  by  the  adhesion 
of  the  mucous  membrane  of  one  wall  with  that  of  the  other  side, 
whilst  alterations  of  this  mucous  membrane  are  revealed  by  the  pre- 
sence of  small  polypoid  excrescences.  There  must  have  been  sterility 
owing  to  these  various  alterations.  In  all  these  preparations  the 
posterior  lip  is  larger  than  the  anterior. 

We  may  also  remark  that  the  tissue  of  the  organ  is  pale  in  place  of 
being  red  from  venous  congestion,  as  is  the  case  in  the  softening  which 
characterises  defective  involution.  The  pale  portion  is  anaemic  owing 
to  the  presence  of  adipose  globules  of  fatty  degeneration,  and  of  white 
globules,  fibrils  of  laminar  tissue,  the  result  of  fibro-muscular  atrophy. 
In  place  of  being  dense  and  hard  this  tissue  is  soft,  and  is  torn  rather 
than  cut  by  the  bistoury;  it  is  only  after  the  retroflexion  has  existed 
for  a  long  time  that,  notwithstanding  the  same  white  aspect,  the 
tissue  changes  its  nature  and  is  formed  of  hard  fibres  of  retractile 
tissue,  some  of  which  are  elastic  and  no  longer  allow  of  the  straightening 
of  the  organ. 


Fig.  293. — Retroflexion  in  the  third  degree,  with  occlusion  of  the  cervico- 
uterine  canal  by  juxtaposition  of  tlie  walls  (after  Graily  Hewitt).  In 
this  figure,  as  in  the  preceding,  the  tissue  of  the  organ  is  anemic  and  pale 
at  the  point  of  flexion. 

Other  alterations  are  not  wanting  which  may  precede  the  develop- 
ment of  retroflexion  or  coexist  with  it,  or  at  least  with  the  softening 
and  tumefaction  characteristic  of  the  defective  involution  which  is  its 
essential  condition  ;  or  they  may  be  produced  in  consequence  of  the 
hindrances  placed  in  the  way  of  the  free  exercise  of  the  functions 
of  the  uterus,  of  impeded  circulation,  of  the  long  duration  of  the 
retroflexion,  &c.  These  alterations  are  pointed  out  in  several  of 
the  rough  drawings  which  I  am  in  the  habit  of  making  in  recording 


436 


TTTEKINE    DISEASES   IN    DETAIL 


cases,  some  of  which  I  have  given  here ;  they  are  peritoneal  adhesions 
of  the  fundus  of  the  uterus  with  the  extremity  of  the  retro- vaginal 


Fig.  294. — Extreme  retroflexion,  from  nature.     Middlesex  Hospital  museum, 

Barnes. 

pouch  of  Douglas,  associated  with  leucorrhoea,  granulations,  vaginal 
cysts,  prolapsus  of  the  ovary,  adenitis  or   nuclei  of  chronic  retro- 


FiG.  295. — Retroflexion  of  the 
second  degree,  "with  bleed- 
ing granular  cervix. 


Fig.  296. — Retroflexion  of  the  first  de- 
gree, probably  congenital :  conicity 
with  hypertrophic  elongation  of 
the  cervix. 


uterine  inflammation,  partial  hypertrophy  of  one  of  the  cervical 
lips,  &c. 

The  subjective  symptoms  of  uncomplicated  retroflexion  are  :  sacral 
pain  at  least  nine  times  out  of  ten,  pain  at  the  anus,  in  the  groins, 
sometimes  at  the  umbilicus,  with  sensation  of  dragging  of  the  navel 
towards  the  pelvis,  especially  in  the  dorsal  decubitus,  with  nausea  and 
stomachic  dyspepsia  as  in  the  commencement  of  pregnancy,  especially 
when  the  fundus  of  the  uterus  is  large,  very  congested  and  very  low. 

The  introduction  of  the  enema  pipe  is  often  sufficient  to  produce 
nausea  in  such  cases  by  coming  in  contact  with  the  fundus  through 
the  rectal  wall.     There  is  also  frequent  desire  to  go  to  stool,  accom- 


FLEXIONS  437 

panied  by  constipation  and  all  its  serious  consequences,  so  vividly 
described  by  Barnes,  frequent  micturition^  increase  of  all  the  pains 


Fig.  297. — Eetroflexion  in  the  first  degree  :  cyst  at  the  extremity  of  the  vagina. 

after  walking  or  exertion  of  any  kind,  even  raising  the  arms  or  ad- 
justing the  hypogastric  belt,  &c. ;  it  is  usually  impossible  to  accom- 
plish any  movement  necessitating  effort  and  causing  compression  of 
the  uterus  by  the  abdominal  viscera.  The  dorsal  decubitus  does  not 
give  any  relief,  and  most  patients  find  out  for  themselves  that  the 
prone  position  is  preferable. 

The  objective  symptoms  are  easily  discovered :  vaginal  touch  prac- 
tised when  the  patient  is  standing,  and  the  same  associated  with  pal- 
pation when  she  is  lying,  will  disclose  a  tumour  behind  the  cervix 
and  continuous  with  it,  the  cervix  being  pushed  forwards  sometimes 
even  against  the  pubis.  When  these  signs  are  observed  there  is  great 
probability  of  our  having  to  do  with  a  retroflexion.  Nevertheless 
we  may  be  mistaken,  diagnosis  being  only  certain  after  the  sound 
has  been  used.  This  is  necessary  in  order  to  ascertain  whether  there 
is  a  retroflexion,  whether  it  is  reducible,  and  if  it  is  so  as  a  whole, 
with  more  or  less  facility,  more  or  less  pain,  &c.  In  trying  to  reduce 
no  risk  is  run  by  using  the  sound,  whilst  one  or  two  fingers  of  the 
other  hand  exercise  pressure  and  raise  the  fundus,  and  the  exactness  of 
the  diagnosis  is  greatly  increased.  It  is  also  important  to  ascertain 
whether  the  ovaries  have  been  dragged  along  with  the  prolapsed 
fundus,  and  if  there  is  adenitis  or  retro-  or  latero-uterine  inflam- 
matory induration  at  the  base  of  the  broad  ligaments,  complications 
which  are  the  source  of  important  indications. 

Treatment  should  be  instituted  as  soon  as  possible  in  order  to  prevent 
alterations  of  organic  tissue  or  peritoneal  adhesions  which  might  pre- 
vent reduction  ;  although  it  must  be  admitted  that,  when  these  altera- 
tions do  not  exist  from  the  beginning,  there  is  less  chance  of  their 
being  developed  later  than  is  generally  supposed.  Eeduction  must 
be  made  possible  by  the  simultaneous  or  previous  cure  of  complications, 
such  as  leucorrhoea,  uterine  granulations,  pelvic  peritonitis,  &c.,  as  in 
anteflexion.  As  a  rule,  neither  inflammation  nor  retraction  have  to  be 
taken  into  account;  in  fact  there  is  no  retraction,  and  as  for  inflamma- 
tion, if  well  managed  it  will  rather  help  to  cure  than  increase  the  evil, 


438 


UTERINE    DISEASES    IN    DETAIL 


by  giving  to  the  uterus  a  rigidity  which  may  prevent  it  from  falling 
backwards.     Lastly,  the  contractility  of  the  uterine  tissue  and  its  liga- 


Fia.  298. — Eetroflexion  in  the  third  degree,  proroinence  of  the  anterior  lip. 
V,  considerable  congestion  o£  the  fundus  ;  o,  prolapsus  of  the  right  ovary ; 
A,  inflammatory  indurations  and  retro-uterine  adenitis. 

ments  must  be  stimulated  in  order  to  produce  this  rigidity  and  retrac- 
tion, which  is  the  contrary  indication  from  that  of  anteflexion. 

1.  In  order  to  effect  reduction  the  hands  may  be  introduced  simul- 
taneously into  the  rectum  and  vagina,  or  one  may  be  introduced  into  one 
of  these  organs  and  the  other  be  applied  to  the  hypogastrium ;  but  it 
is  best  to  combine  the  use  of  the  sound  with  that  of  the  fingers  in  the 
rectum  or  the  posterior  vaginal  cul-de-sac.  Reduction  is  facilitated  by 
the  genupectoral  posture,  although  this  is  not  indispensable ;  it  often 
suffices  to  place  the  patient  on  her  back  if  the  sound  is  ased.  {See 
Pig.  128,  p.  145.) 

3.  After  the  fundus  has  been  raised  and  the  cervix  has  been  pushed 
back  into  the  sacral  cavity  I  introduce  the  galvanic  stem  pessary, 
keeping  it  in  place  by  a  tampon  saturated  in  glycerine.  The  patient 
should  then  assume  the  'ventral  decubitus  for  a  few  hours.  This 
application  may  be  repeated  twice  a  week.  The  intra-uterine  stem  is 
made  in  four  sizes  so  as  to  suit  all  cases.  If  this  is  contra-indicated 
by  leucorrhoea  or  endometritis,  a  sponge  or  plug  of  cotton  wool 
saturated  in  tannin  may  replace  it  or  my  lever  pessary  with  a 
cervical  arch  {see  Fig.  177,  p.  198),  the  arch  being  placed  in  front 


FLEXIONS 


439 


of  the  cervix  to  keep  it  iu  the  concavity  of  the  sacrum^  and  to 
incline  the  fundus  forwards,  which  is  the  best  way  of  prevent- 
ing it  from  falling  back  again.  The  patient  should  continue 
to  adopt  the  ventral  decubitus,  sometimes 
remaining  in  it  day  and  night,  at  any  rate 
always  at  night,  and  to  be  sure  that  the  uterus 
is  in  its  normal  direction  it  is  well  to  teach  the 
husband  or  nurse  of  the  patient  to  introduce  a 
small  Fergusson's  speculum  into  the  posterior 
vaginal  cul-de-sac  every  night  at  bedtime  while 
the  patient  is  in  the  genupectoral  posture,  and 
then  to  withdraw  it  very  gently,  inclining  the  ex- 
ternal extremity  as  low  as  possible;  in  this  way 
the  atmospheric  air  is  admitted  into  the  vagina, 
the  pressure  reaching  the  extremity  of  this  canal 
and  causing  the  intestinal  mass  and  the  fundus 
to  fall  towards  the  lower  abdominal  wall  ac- 
cording toCampbelPs  method  already  described. 
3.  It  is  not  enough  to  reduce  the  retroflexion 
nor  to  maintain  it  reduced ;  the  tissue  must  be 
stimulated.  Eetention  therefore  should  be  aided 
by  cold  sitz- baths,  cold  astringent  injections, 
electricity,  strychnia,  ergot,  &c,  which  excite  contraction  of  the  organ, 
and  restore  to  the  tissue  the  rigidity  without  which  cure  would  be 
impossible. 


Fig.  299.  —  Galvanic 
stem  pessary,  re- 
tained by  a  tampon 
of  cotton-wool  in  a 
retroflexed  uterus 
previously  reduced. 


Fig.  300. — Galvanic  stem  pessary,  retained  by  a  tampon  in  tlie  I'odnced  uteras, 
the  patient  being  in  the  abdominal  decubitus. 


440 


UTERINE    DISEASES    IN    DETAIL 


4.  Complications  such  as  leucorrhoea,  granulations,  hypertrophic 
congestion,  &c.,  should  be  treated  simultaneously  by  the  usual  means 
(glycerine,  plugs,  cauterisation,  ignipuncture,  &c.). 

5.  Lastly,  tonics  and  restoratives,  hydropathy,  sea  bathing,  iron, 
bark  and  generous  diet  will  greatly  contribute  to  the  success  of  the 
treatment. 

In  closing  I  shall  merely  add  a  brief  summary  of  two  very  curious 
cases  of  gastrotomy  performed  for  the  cure  of  retroflexion.  Koeberle^ 
performed  gastrotomy  in  a  Polish  lady  of  twenty-two  years  who  had 
suffered  excruciating  pain  for  two  and  a  half  years  previously ;  after 
an  incision  of  from  one  and  a  half  to  two  inches  of  the  peritoneum, 
the  uterus  was  drawn  upwards  with  the  fingers  and  the  left  ovary 
with  its  ligament  inserted  into  the  abdominal  incision ;  the  ligament  was 
left  one  and  a  half  inches  long  so  as  to  keep  the  uterus  in  normal 
position ;  the  operation  was  followed  by  cure. 

Sims^  performed  the  same  operation  on  a  widow  of  thirty-two 
years,  February  2£nd,  1875  ;  he  removed  the  left  ovary,  which  was 
the  size  of  a  nut  and  affected  with  cystic  degeneration,  including  the 
pedicle  in  the  angle  of  incision,  so  as  to  retain  the  uterus  in  its  normal 
position.  The  operation  resulted  in  the  cure  of  the  patient  who  had 
suffered  great  pain  for  several  years.  I  do  not  quote  these  operations 
as  examples  to  be  followed,  but  as  showing  that  flexions  are  painful 
maladies,  and  that  the  pain  may  be  cured  by  reducing  the  flexion. 
These  cases  are  worthy  of  notice  from  this  point  of  view  as  vv^ell  as 
from  the  success  attending  enterprising  surgery. 

Inversion 

Inversion  is  the  position  taken  by  the  fundus  and  walls  of  the 
uterus  when  this  organ  is  turned  back  on  itself  like  the  finger  of  a 


Fig.  301. — Eversion  or  ectropion  of  tlie  mucous  membrane  of  the  neck. 

glove,  the  internal  and  concave  surface  becoming  external  and  convex, 
and  vice  versa. 

^  TJeber  eine  radicale  Operation  zur  Beseitigung  der  Betroversio  tmd  Retro- 
flexio  Uteri,  erzdhlt  von  Schetelig  in  deni  Centralblatt  fiir  medicinische  Wis- 
senschaften,  June,  1869,  S.  417. 

^  British  Medical  Journal,  Dec.  15,  1877,  p.  840. 


INVERSION 


441 


Uterine  inversion^  like  every  displacement,  presents  several  degrees. 
Leroux,  of  Dijon^^  distinguished  three  degrees,  which  since  then  have 
been  generally  admitted,  and  to  which  the  names  of  simple  depression, 
introversion  (Crosse)  and  inversion  may  be  given. 

I  think  two  degrees  are  sufficient :  complete  and  incomplete  inver- 
sion.^ 

I  call  incomplete  or  partial  inversion  that  in  which  the  uterus  is  not 
entirely  inverted  on  itself.  Whether  there  is  simple  depression  of  the 
fundus  of  the  organ,  invagination  of  the  fundus  into  the  body,  penetra- 
tion of  the  inverted  portion  through  the  neck  and  even  commencement 
of  the  escape  of  the  organ  by  the  orifice — these  are  only  shades  or 
degrees  in  the  accomplishment  of  the  phenomenon ;  but  these  degrees 
do  not  involve  any  difference  with  regard  to  the  symptoms  experienced 
by  the  patient,  the  indications  to  be  fulfilled  nor  the  facility  of  reduc- 
tion (l^ig.  302).     I  call  complete  or  total  inversion  that  in  which  the 


Fig.  302. — Incomplete  inversion  of  the  uterus  (after  J.  G.  Forbes). 

uterus,  body  and  neck,  is  entirely  turned  back  on  itself,  whether  the 
border  formed  by  the  cervix  shares  in  the  inversion  or  not  (Fig.  303). 
As  for  the  vaginal  inversion  which  drags  the  uterus  out  of  the  vulva 
with  it,  it  is  a  compHcation  of  uterine  inversion  (Fig.  304). 

1  Op.  cit.,  p.  59. 

^  In  these  degrees  I  do  not  include  eversion  or  ectropion  of  the  cervix,  which 
begins  at  the  os  externum  in  place  of  at  the  fundus.  This  eversion  is  seen  in 
the  widely  open,  soft  dilatable  cervix,  and  is  in  such  cases  prodiiced  at  every 
examination  when  the  bivalve  speculum  is  used,  owing  to  the  separation  of  the 
two  valves  of  the  instrument ;  the  two  columns  of  the  arbor  vitte  are  seen 
with  their  secondary  projections  and  the  subdivisions  of  these  prominences, 
made  unequal  by  the  disseminated  glands.  It  may  be  produced  spontaneously 
as  the  result  of  contraction  of  the  upper  circular  ring  of  muscular  fibres  of 
the  cervix,  coinciding  with  the  softness  of  the  lower  vaginal  portion  of  the 
cervical  lips.  But  it  does  not  go  farther,  and  such  an  eversion  never  ends  in 
real  inversion  of  the  organ  as  occurs  when  the  malady  commences  by  depression 
of  the  fundus  like  the  l3ottom  of  a  wine  bottle. 


442 


UTEEINE    DISEASES  IN    DETAIL 


A  combination  of  circumstances  are  required  to  produce  uterine 
inversion.     It  usually  occurs  after  delivery  (according  to  Crosse  350 


FiQ".  303. — Complete  inversion.  From  an  original  drawing  by  Biot  for  Crosse's 
Essay  on  Inversio  Uteri,  representing  a  preparation  in  Dupuytren's 
Museum,  -|  natural  size.  The  patient  died  from  exhaustion  twenty-two 
months  after  delivery,  v,  vagina  ;  u  c,  incised  uterus,  showing  the  cavity  ; 
6,  border  of  the  inverted  portion,  the  round  ligaments,  Fallopian  tubes 
and  the  ovarian  ligaments  are  drawn  in  it ;  Z  r,  round  ligaments  ;  t,  Fal- 
lopian tubes  ;  o  o,  ovaries  ;  h,  cervix  covered  by  peritoneum. 


Fig.  304. — Complete  inversion  of  the  uterus,  complicated  with  vaginal 
invasination. 


INVEESION  443 

times  out  of  400  inversions),  and  even  after  abortion  or  miscarriage.^ 
It  may,  however,  be  produced  in  other  conditions,  e.g.  it  may  be 
determined  by  the  existence  of  dropsy,  the  presence  of  a  fibroid  or 
polypus,  the  natural  expulsion  of  these  products  or  attempted  extrac- 
tion of  these  tumours. 

The  previous  development  of  the  uterus  by  the  product  of  concep- 
tion, a  polypus,  water  or  blood,  the  weakening  of  the  vital  properties, 
of  the  muscular  contractility  of  this  organ,  and  even  a  congenital  vice  in 
its  conformation,  may  be  regarded  as  predisposing  causes  of  inversion. 

The  determining  causes  are  those  in  which  the  action  of  some  power 
is  brought  into  play  on  the  fundus  of  the  organ,  which  it  depresses, 
attracts  or  pushes  towards  its  cavity.  Inertia  of  the  uterus,  shortness 
of  the  cord,  and  especially  adhesions  of  the  placenta,  may  determine 
inversion ;  prolonged  or  violent  expulsive  efforts  at  or  after  delivery, 
undue  traction  on  the  cord  by  the  midwife  or  by  the  weight  of  the 
child  escaping  suddenly,  may  also  determine  it.  It  appears  also  that 
coincidence  of  inertia  of  the  lower  portion  with  violent  contractions  of 
the  upper  part  of  the  uterus,  either  during  delivery  or  afterwards,  may 
produce  spontaneous  uterine  invagination,^  as  has  been  proved  in  a  few 
cases.^ 

In  the  case  of  delivery  the  inversion  may  occur  at  two  different 
periods  : — 1,  when  the  fcetus  is  expelled,  owing  to  uterine  inertia  and 
to  traction  exercised  by  the  foetus  on  too  short  a  cord,  especially  if  the 
woman  is  standing ;  2,  when  the  placenta  is  expelled,  generally  owing 
to  the  persistence  of  the  utero-placental  connections  and  to  the 
solidity  of  the  cord.  In  these  cases  inversion  may  at  first  be  incom- 
plete ;  but  it  is  almost  always  completed  by  uterine  contraction  under 
the  influence  of  the  impulse  given  by  the  efforts  of  the  patient,  the 
pressure  of  the  intestines  and  abdominal  viscera,  &c.  It  is  rather  in 
cases  of  polypi  and  fibromata*  that  incomplete  inversions  occur,  which 
may  remain  for  some  time  in  the  same  state.  In  some  circumstances 
inversion  and  even  prolapsus  uteri  may  be  seen  in  nulliparae.^ 

'  Partial  inversion  at  the  fifth  month,  by  Dr.  Spae,  Northern  Journal  of 
Medicine,  July,  1845. — Complete  inversion  at  the  fifth  month,  by  Dr.  John 
Brady,  New  Yorh  Medical  Times,  Feb.,  1856. — Complete  inversion  of  the 
uterus  at  the  fourth  month  of  gestation,  replaced  six  days  after  the  accident 
by  E.  W.  Wodson,  M.D.,  of  Woodville,  Kentucky,  American  Journal  of  the 
Medical  Sciences,  October,  1860. 

^  Leroux,  Pertes,  p.  56. — Ane  et  Baudelocque,  according  to  Dailliez,  op.  cit. — 
Mai-jolin  and  Dupuytren,  in  a  nullipara.  Diet,  en  30  vol.,  art.  Uterus,  t.  xxx,  p. 
295.  Paris,  1846. 

^  Ruysch,  Case  x. — Ch.  Cowan,  in  Montpellier  medical,  t.  x,  p.  563,  June, 
1863. — This  opinion  is  also  shared  by  Saxtorph,  Radfort,  Simpson,  West.  We 
must,  however,  remember  that  the  rarity  of  inversion  in  maternity  hospitals  is 
itself  a  proof  of  the  rarity  of  the  spontaneous  production  of  uterine  inversion 
during  labour.  As  for  the  spontaneous  production  of  uterine  inversion  occurring 
gradually  in  the  case  of  the  expulsion  of  a  polypus  or  in  analogous  circum- 
stances, it  can  no  more  be  doubted  than  the  fact  o£  spontaneous  reduction  under 
the  influence  of  the  continued  pressure  of  an  air  pessary. 

■*  Thomas  Denman,  Collection  of  Engravings,  &c.  London,  1787,  and  Segard, 
Stir  les  polypes  uterins.  These  de  Paris,  1804,  No.  246. 

*  Sayi-e,  of  New  York,  quoted  by  Marion  Sims,  p.  147  ;  McClintock,  op.  cit., 
p.  98. 


444  UTERINE    DISEASES    IN    DETAIL 

Immediately  after  delivery  the  uterus  usually  diminishes  in  size 
owing  to  muscular  contraction,  hardening  in  the  form  of  a  ball,  the 
globus  of  accoucheurs.  If  there  is  inertia,  it  remains  soft  and,  under 
the  influence  of  the  determining  cause  acting  on  it,  begins  by  being 
depressed  at  some  point,  usually  at  the  fundus.^  The  borders  of  this 
depression  are  more  raised  on  the  side  of  the  pubis  than  on  that  of 
the  sacrum,  are  inclined  to  one  side  or  the  other  according  to  the 
obliquity  of  the  uterus  and  vary  in  their  inclination,  according  to 
whether  the  depression,  in  place  of  affecting  the  fundus  itself,  is  pro- 
duced on  the  posterior  or  anterior  surface,  or  on  one  of  the  borders. 
At  this  moment  the  placenta  enters  the  neck ;  it  is  solid  to  the 
touch  and  apparently  of  larger  size  than  normally.  Traction  on  the 
cord  brings  it  down  and  in  proportion  as  it  descends,  the  peritoneo- 
uterine  fossa  increases  in  depth  and  diminishes  in  width  at  its 
entrance,  the  inversion  increasing  in  proportion  as  the  placenta  pro- 
ceeds. These  facts  are  easily  verified  in  thin  women  who  have  had 
children.  Simple  depression  of  the  fundus  or  of  one  of  the  walls  is 
not  painful,  especially  when  inversion  is  produced  slowly  by  the 
natural  or  artificial  expulsion  of  a  polypus,  in  place  of  occurring  sud- 
denly by  that  of  the  foetus;  in  such  cases  the  woman  may  not  be 
conscious  of  any  change. 

If  the  inversion  increases  it  determines  painful  dragging  round  the 
pelvis.  If  it  occurs  suddenly  it  causes  excruciating  pain ;  this  is 
followed  by  syncope  and  haemorrhage  which  increases  in  proportion  as 
the  placenta  is  detached,  diminishing  momentarily  after  uterine  contrac- 
tion, but  often  causing  great  anxiety.  The  hsemorrhage  by  increasing 
the  weakness  and  inertia  of  the  organ  leads  to  the  recurrence  of 
syncope  and  then  exhaustion  brings  on  convulsions.  If  the  women 
have  sufficient  blood  and  strength  left,  the  haemorrhage  may  be 
stopped  for  the  time  and  recur  again.  But  even  then  the  patients 
lose  all  hope  of  recovery  and  remain  in  a  deplorable  state  of  health 
which  increases  every  day. 

Diagnosis — subjective  signs. — The  sudden  sensation  of  displace- 
ment at  the  time  of  delivery,  the  excruciating  pain  which  announces 
the  fact,  the  sudden  collapse,  the  abundant  hsemorrhage  which  follows, 
the  absence  of  the  globus  uterinus  in  the  hypogastrium,  the  sensations 
of  dragging,  of  weight,  and,  later  on,  of  pain  in  every  movement, 
especially  when  coitus  is  attempted,  serious  hsemorrhage  at  the 
monthly  period  followed  by  abundant  leucorrhcea,  ansemia  and  the 
incapacity  of  the  patient  for  walking  or  any  kind  of  exertion  are  very 
characteristic  symptoms  of  inversion.  As  for  the  general  symptoms, 
some,  such  as  ansemia,  are  the  result  of  hsemorrhage ;  others,  such  as 
acute  abdominal  pain,  troublesome  dragging  in  the  groins  and  pelvis 
with  indescribable  discomfort  in  the  hypogastric  region,  vomiting  and 
tenesmus,  depend  on  the  displacement  itself;  others  again,  such  as 
syncope  and  convulsions,  are  secondary.  Cases  have  occurred,  such 
as  the  three  mentioned  by  West,  where  the  accident  was  unnoticed 

^  Traits  des  maladies  des  femmes  grosses  et  de  celles  qui  sont  accouchees, 
t.  ii,  p.  186.  Paris,  1740. 


INVERSION 


445 


when  it  first  occurred,  and  others,  such  as  that  of  Madame  Boivin, 
those  of  Lisfranc,  that  of  Woodman  ^  and  two  others  communicated  to 


Fig.  305. — Complete  and  recent  inversion,  from  a  preparation  in  wax  in  Du- 
puytren's  museum,  moulded  from  a  woman  who  died  of  haemorrhage 
caused  by  inversion  a  few  hours  after  delivery.  (Heurteloup's  case,  taken 
from  Breschet's  Repertoire  d'anaiomie).  e,  rectum  ;  b,  bladder:  v,  v,  an- 
terior and  posterior  projections  of  the  peritoneal  infundibulum,  on  a  level 
with  the  neck,  into  which  the  round  ligaments,  the  Fallopian  tubes  T,  and 
the  ovarian  ligaments  o,  are  dragged. 

me  by  esteemed  practitioners  where  the  malady  was  merely  inconve- 
nient. These,  however,  are  rare  exceptions,  and  it  is  to  be  remarked 
that  these  patients  were  aged. 

Objective  signs. — Inversion  is  easily  diagnosed  by  touch  combined 
with  palpation.  The  upper  border  of  the  tumour  is  hardly  perceptible 
by  abdominal  palpation.  Adhesion  of  the  placenta  may  drag  the 
fundus  of  the  inverted  uterus  outside  the  vulva;  in  such  cases  the 
serous,  amniotic,  smooth  and  polished  surface  covering  the  placenta  is 
seen.  If  the  placenta  has  been  detached  from  the  uterus,  the  tumour 
is  smaller  and  its  surface  different  in  aspect,  it  is  downy  and  shows  the 
orifices  of  the  uterine  sinuses.  The  tumour  is  elongated  in  proportion 
as  it  has  inverted  and  dragged  with  it  the  vagina.     Hypogastric  pal- 

'  Obstetrical  Transactions,  1867.  Inversion  had  existed  for  five  years  in  a 
woman  of  fifty. 


446 


UTEEIXE    DISEASES    IN    DETAIL 


pation  allows  of  measuring  the  pelvis  without  finding  the  uterus  in  it, 
and  consequently  of  distinguishing  the  inverted  uterus  and  its  cap-like 

OS  from  the  foetal  head  or  a  mole 
which  may  also  appear  at  the  vulva. 
Differential  diagnosis. — Involu- 
tion of  the  uterus  is  effected  more 
slowly  after  inversion  than  after  a 
normal  delivery.  The  uterus  takes 
five  or  six  months  to  come  back  to 
its  normal  size,  endangering  life 
by  repeated  hsemorrhage  when  the 
patient  has  had  the  good  fortune 
to  survive  the  terrible  haemorrhage 
which  usually  accompanies  inver- 
sion. It  is  at  this  period  that  an 
inverted  uterus  might  be  taken  for 
a  polypus,  when  if  ablation  was  per- 
formed death  would  result,  and  the 
application  of  a  ligature  would  be 
hardly  less  dangerous.  When,  how- 
ever, inversion  is  recent,  diagnosis 
is  easy.  Examination  of  the  ab- 
domen shows  the  absence  of  the 
uterus  from  the  hypogastrium.  This 
must  be  due  either  to  prolapsus  or 
inversion  and  vaginal  touch  decides 
the  question  :  in  inversion  there  is 
absence  of  the  cervix  from  the 
lower  portion  of  the  tumour,  the 
pear-shaped  aspect  of  the  latter 
presenting  its  small  extremity  above 
m  place  of  below,  as  in  prolapsus ; 
a  portion  of  the  length  of  the  vagina 
usually  remains  contained  in  the 
pelvic  cavity ;  sometimes  in  the 
upper  portion  of  the  tumour  there 
exists  a  circular  border  formed   bv 


Fig.  306. — Antero-posterior  longitu- 
dinal section  of  the  preparation 
representing  the  case  of  uterine 
inversion  observed  by  Heurteloup 
(Fig.  305).  E,  rectum;  r,  in- 
vei-ted  uterus,  the  convex  surface 
having  become  concave,  contained 
in  the  vagina  v ;  B,  bladder  ;  p, 
peritoneal  infundibulum  at  the 
neck. 


the  vaginal  portion  of  the  cervix. 
When  inversion  is  of  long  standing  the  tumour  is  usually  contained 
in  the  vagina.  Its  surface  may  be  recognised  by  the  help  of  the  spe- 
culum, its  form,  size  and  connections  by  touch.  A  red  tumour  is 
perceived,  which  is  rounded,  sometimes  soft  and  downy,  sometimes 
(.by  and  rugged,  connected  with  the  vagina  by  a  broad  and  short 
pedicle  of  large  transverse  diameter,  separated  from  the  vaginal  cul-de- 
sac  or  from  the  circular  border  of  the  vaginal  portion  of  the  cervix  by 
a  groove  which  disappears  on  traction.  This  tumour  presents  no 
orifice  at  all  like  the  os.  After  a  careful  search  the  orifices  of  the 
Pallopian  tubes  may  be  found;  the  characteristics  of  the  internal 
surface  of  the  uterus  may  often  be  recognised,  especially  if  the  tumour 


INVERSION  447 

is  drawn  outside  and  examined  at  tlie  menstrual  period.  Catheterism, 
rectal  touch,  hypogastric  palpation,  associated  with  vaginal  touch, 
enable  us  to  make  sure  of  the  total  absence  of  the  uterus  above  the 
pedicle  of  the  tumour  and  of  its  presence  somewhere  in  the  pelvic 
cavity,  either  in  its  normal  direction  or  flexed  forwards  or  backwards. 
I  know  that  distinguished  practitioners  have  failed  to  diagnose  inver- 
sion and  have  cut  an  inverted  uterus  of  some  months'  standing 
believing  it  to  be  a  polypus.  A  pediculated  or  non-pediculated  fibroid 
or  polypus  are  all  the  more  easily  confounded  with  inversion  that  they 
themselves  may  determine  it,  and  so  may  present  a  complex  malady 
for  the  diagnosis  of  the  physician.  But  although  inversion  may 
resemble  a  polypus  in  form,  size  and  consistency,  it  differs  in  the 
following  characters :  the  pedicle  of  the  polypus  is  longer  and  thinner 
than  that  of  the  inverted  uterus,  and  descends  from  the  border  of  the 
orifice  into  which  the  finger  can  be  introduced ;  the  sound,  if  not  the 
finger,  can  pass  all  round  it  (between  this  pedicle  and  the  cervix  which 
serves  as  a  sheath)  reaching  the  uterine  cavity  at  different  heights ;  in 
fact,  hypogastric  palpation  and  rectal  touch  discover  the  fundus  of  the 
uterus  somewhere  in  the  pelvic  cavity.  The  case  is  more  diflicult 
when,  after  the  ablation  of  a  polypus,  another  intra-uterine  tumour  is 
seen  in  the  half  open  cervix,  which  may  either  be  a  second  polypus  or 
the  uterus  partially  inverted.  In  such  a  case  Gueniot-^  determined 
the  diagnosis  by  ascertaining  by  means  of  acupunctv/re  the  insensibility 
and  density  of  the  tumour,  characteristic  of  a  fibrous  polypus,  in  con- 
trast with  the  softness  and  sensibility  which  the  inverted  uterine  tissue 
presents.  Prolapsus,  as  we  have  already  said,  forms  a  larger  tumour 
above  than  below,  showing  the  os  at  its  lower  extremity.  If  it  is 
complete  and  complicated  with  prolapsus  of  the  vagina,  cystocele  or 
rectocele,  it  is  still  more  easily  distinguished  from  inversion  because 
the  pressure  of  these  tumours  excites  the  desire  of  micturition,  the 
escape  of  the  urine  or  the  faeces.  Simple  cystocele  and  rectocele  are  still 
more  easily  distinguished :  the  pressure  of  the  os  in  the  vagina  and  of 
the  fundus  in  the  pelvic- abdominal  cavity  will  always  be  certain  means 
of  diagnosis.  Nevertheless,  it  might  be  difficult  after  delivery  to 
recognise  inversion  in  a  woman  who  had  during  pregnancy  a  tumour 
independent  of  the  uterus,  like  an  ovarian  cyst,  preventing  examina- 
tion of  the  pelvic  cavity  by  hypogastric  palpation. 

Treatment. — Uterine  inversion  is  one  of  the  most  serious  maladies. 
A  number  of  women  succumb  immediately  after  the  accident.  Accord- 
ing to  Crosse-  out  of  109  patients  who  have  succumbed  to  uterine 
inversion,  72  died  a  few  hours  after  delivery,  8  at  the  end  of  a  week, 
and  6  in  a  month.  The  patient  dies  from  hEemorrhage,  pain,  con- 
vulsions, or  syncope  caused  by  shock,  from  exhaustion,  or  from  the 
effects  of  violence,  especially  if  the  inversion  has  been  taken  for  a 
polypus  and  has  been  dragged,  bruised  or  lacerated.     \A^hen  imme- 

'  De  I'acupuncturc  consideree  comme  nioyen  de  diagnostic  diffevential  entre 
covtains  polypes  fibreiix  de  la  matrice  et  le  renvevsement  paiiial  de  cet  organe. 
Archives  generales  de  viedecine,  April,  1868. 

^  Transactions  of  the  Prov.  Med.  and  Surg.  Association,  vol.  xv,  p.  340. 
London.  1817. 


448  UTERINE    DISEASES   IN    DETAIL 

diate  danger  is  dissipated,  there  is  during  lactation  an  interval  of 
relative  safety  when  serious  symptoms  frequently  cease,  only  to  reappear 
later  on.  The  inverted  uterus  may  be  strangulated  especially  if  in- 
version is  incomplete ;  Dewes  completed  inversion  in  a  patient  in 
order  to  put  a  stop  to  strangulation.  This  accident  may  be  serious 
enough  to  produce  gangrene  of  the  organ  (Crosse  gives  several  cases) 
and  IS  consequently  very  dangerous  unless  spontaneous  elimination  of 
the  gangrenous  uterus  terminates  the  malady  favorably.  I  have  seen 
a  case  of  this  kind,  otherwise  I  should  have  difficulty  in  believing  it. 
As  for  spontaneous  reduction,  it  is  extremely  rare.  Although  the 
patient  has  not  succumbed  to  the  shock,  or  to  hsemorrhage,  exhaus- 
tion or  gangrene,  she  is  not  on  that  account  out  of  danger ;  for  she 
is  liable  to  profuse  haemorrhage  which  recurs  in  the  intercalary  period 
as  well  as  at  menstruation,  and  continues  till  after  reduction  of  the 
tumour  or  the  menopause,  patients  during  all  this  time  running  the 
risk  of  a  fatal  loss  of  blood.  I  knew  a  lady  who  remained  thirty 
years  in  this  state,  and  whose  health  only  slightly  improved  after  the 
menopause.  Stevens  of  New  York  has  also  seen  chronic  inversion  ex- 
pose a  patient  to  very  dangerous  periodical  haemorrhages  which  ceased  at 
the  climacteric.  An  analogous  case  is  given  by  Lee.  In  cases  where 
adhesions  are  not  produced,  or  where  a  strong  contraction  to  the 
cervix  has  not  effaced  the  entrance  to  the  inverted  uterine  cavity,  a 
portion  of  the  intestine  may  insinuate  itself,^  become  strangulated 
and  cause  symptoms  which  may  wrongly  be  interpreted  as  sympa- 
thetic, such  as  pain  in  the  bowels,  tumefaction  of  the  belly,  vomiting 
and  hiccough,  and  which  may  terminate  fatally.  Lastly,  supposing 
that  the  life  of  the  patient  is  not  in  constant  danger  it  is  one  of  great 
trial.  Besides  the  persistence  of  pain,  hsemorrhage,  leucorrhoea,  and 
weakness  which  make  life  miserable,  she  necessarily  becomes  sterile 
and  incapable  of  marital  intercourse.  Chevreuil's^  case,  communicated 
to  Baudelocque,  in  which  tubular  pregnancy  occurred  in  a  woman 
affected  with  uterine  inversion  is  quite  exceptional,  as  well  as  one 
known  to  myself,  where  the  patient  was  able  to  have  intercourse  with- 
out much  inconvenience  in  spite  of  inversion.  Therefore,  although  not 
dangerous  in  itself,  inversion  of  the  womb  may  suddenly  become  fatal 
or  cause  accidents  which  last  during  life.  The  woman  who  has  escaped 
the  immediate  consequences  is  liable  to  greater  ones  later  on.  There- 
fore great  care  should  be  taken  to  prevent  the  occurrence  of  inversion. 
The  woman  should  be  dehvered  when  lying ;  the  uterine  contractions 
should  be  dimimshed,if  they  are  too  violent  and  too  frequent;  stimulated 
if  the  organ  is  threatened  with  inertia  ;  only  moderate  traction  should 
be  exercised  on  the  chord ;  the  hand  should  be  introduced  into  the 
uterus  to  remove  the  placenta  if  it  is  adherent;  after  the  delivery  of 
the  afterbirth,  the  cervix  should  be  titillated  and  friction  should  be 
applied  to  the  fundus  through  the  hypogastrium  to  determine  contrac- 

*  Baudelocque  showed  Dailliez  (op.  cit.,  p.  179)  the  drawing  of  an  incom- 
pletely inverted  uterus,  the  cavity  of  which  contained  several  intestinal  circum- 
volutions. 

2  Dailliez,  op.  cit.,  p.  80. 


INVERSION  449 

tion  of  the  uterine  fibres  and  the  formation  of  the  hard  and  resisting 
glohts ;  lastly,  the  patient  should  be  advised  to  avoid  efforts,  falls, 
jumping  out  of  bed,  and  all  movements  which  may  occasion  total 
or  partial  displacement  of  the  uterus  whilst  incompletely  contracted. 
If  inversion  is  effected,  reduction  should  be  made  as  soon  as  possible. 

I.  Reduction  of  the  tumour. — If  inversion  has  taken  place  it  must  be 
reduced  by  turning  the  uterus  in  on  itself,  so  as  to  make  each  of  its 
surfaces  resume  the  relative  position  which  belongs  to  it ;  such  is  the 
chief  indication.  Now  reduction  varies  according  to  the  degree  of 
inversion,  the  absence  or  presence  of  the  placenta,  the  position  of  the 
uterus  outside  the  vulva,  or  in  the  vagina,  the  period  at  which  the 
operation  may  be  attempted,  the  manner  of  performing  it,  the  instru- 
ments and  the  methods  which  are  applicable  to  it. 

1.  At  the  time  of  delivery  inversion,  as  a  rule,  should  be  reduced  as 
soon  as  possible ;  but  this  reduction,  though  comparatively  easy  when 
attempted  at  once,  may  be  more  difficult  after  a  few  hours  than  after 
a  few  days.  It  is  the  same  with  uterine  inversion  as  with  all  trau- 
matisms :  simple  at  first,  it  soon  becomes  complicated  with  the  usual 
consequences,  congestion,  inflammation,  &c.,  which  may  become  the 
source  of  special  indications,  resuming  afterwards  its  primitive  state  of 
simplicity  with  its  natural  consequences  or  the  consecutive  complica- 
tions which  are  peculiar  to  it.  Tiierefore  the  most  favorable  time  for 
reduction  is  the  earliest  possible.  If  this  earliest  time  has  been  allowed 
to  pass  we  may  be  obliged  to  wait  for  some  days.  Lauverjat^  reduced 
an  inversion  ten  or  twelve  days  after  delivery.  After  this  period  any 
time  is  good.  Only  it  is  prudent  to  choose  the  middle  of  the  month 
between  two  periods,  so  as  to  have  to  do  with  an  uncongested  organ 
and  to  run  less  risk  of  inflammatory  accidents. 

There  is  great  difi'erence  of  opinion  among  surgeons  as  to  what 
should  be  done  in  cases  of  adherent  placenta  :  some  think  it  should  be 
reduced  with  the  uterus ;  others  that  it  should  be  removed  before  re- 
duction is  made.  As  a  rule,  I  think  that  reduction  is  facilitated  by 
the  removal  of  the  placenta  :  the  tumour  is  so  large  and  its  passage 
through  the  cervix  so  difficult  that  we  should  try  to  diminish  the  size 
of  the  organ  to  be  reduced ;  by  operating  promptly  we  may  hope  to 
avoid  much  hsemorrhage,  which,  besides,  can  be  more  easily  arrested 
after  than  before  reduction  by  compression  of  the  aorta,  friction  of  the 
hypogastrium,  titillation  of  the  cervix,  and  the  administration  of  ergot, 
especially  if  the  hsemorrhage  is  from  the  placenta  ratljer  than  the 
uterus.  When  inversion  is  complicated  with  prolapsus  the  difficulty 
of  reduction  is  not  greatly  increased ;  if  the  uterus  is  in  the  vagina  it 
may  be  well  to  draw  it  outside  the  vulva,  after  performing  taxis  as  I 
have  recommended.  In  any  case,  and  at  whatever  period  we  are  called 
on  to  treat  the  malady,  reduction  of  the  prolapsus  should  always  be 
eft'ected  even  if  that  of  the  inversion  cannot  be. 

When  some  hours  have  passed  without  reducing  the  tumour  it  may 
be  well  to  prepare  the  way  for  reduction  by  the  use  of  difi'erent  means, 

*  Nouvelle  mcthode  de  j)ratiquer  V operation  cesarienne.  Paris,  1788. — 
Dailliez,  op.  cit.,  p.  82. — Churcliill,  op.  eit.,  p.  480. 

29 


450  UTEEINE    DISEASES   IN    DETAIL 

according  to  the  period  when  operation  is  called  for  :  sometimes  by 
antiphlogistics,  emollients  and  rest,  if  the  tumour  has  been  formed  for 
some  time  and  is  the  seat  of  inflammatory  phenomena ;  sometimes  by 
sedatives,  narcotics  and  belladonna,  to  prevent  muscular  contraction 
and  to  relax  the  circular  fibres  of  the  cervix ;  sometimes  by  direct  com- 
pression of  the  organ  by  an  air  pessary  or  by  a  stem,  so  as  gradually  to 
force  the  resistance  of  these  circular  fibres  of  the  cervix ;  sometimes 
by  destructive  cauterisation  of  the  mucous  membrane  on  the  fundus 
of  the  organ,  so  as  to  provoke  contractions  in  the  tissue  proper  which 
determine  spontaneous  reduction;  sometimes  direct  section  of  the  cir- 
cular fibres  of  the  isthmus  at  the  time  when  reduction  is  attempted,  to 
put  a  stop  to  the  resistance  of  this  contractile  ring. 

The  posture  of  the  patient  most  favorable  to  reduction  is  the  dorsal 
decubitus  on  the  edge  of  the  bed,  the  pelvis  raised,  the  head  and  trunk 
low,  the  legs  held  flexed  and  separated  by  assistants ;  another  assistant 
should  depress  the  hypogastrium  and  try  with  his  hand  to  fix  the  cir- 
cular border  of  the  cervix  in  the  cavity,  to  prevent  it  from  rising,  a 
useless  precaution  when  my  method  is  followed.  When  no  effort  is 
required  to  cross  the  sphincter  of  the  cervix,  the  genupectoral  position 
would  facilitate  the  reduction :  it  may  therefore  be  utilised  in  certain 
cases,  especially  in  those  of  incomplete  inversion. 

As  for  the  indrnments  required  for  this  operation  there  are  none  so 
good  as  the  hands ;  they  are  the  only  instruments  that  should  be 
used :  one  to  exercise  pressure  on  the  inverted  uterus ;  the  other  to 
retain  the  cervix  and  fix  the  organ,  without  which  we  should  have  no 
hold  on  it. 

The  hand  exercising  taxis  may  act  in  several  ways,  according  to  the 
period  when  reduction  is  made  or  the  method  employed.  It  was  with 
the  fist  that  Levret  reduced  the  womb  of  a  woman  who  had  been  de- 
livered standing,  and  with  two  fingers  that  Baudelocque  made  it  pass 
through  a  somewhat  contracted  orifice  seven  hours  after  delivery.  In 
these  cases  pressure  is  exercised  on  the  centre  of  the  organ  so  as  to 
depress  it  in  an  opposite  direction  from  the  depression  which  has 
characterised  the  commencement  of  the  inversion.  According  to  the 
size  of  the  womb  at  the  time,  we  may  push  the  fundus  back  with  one 
finger  or  with  two  like  Baudelocque,  or  we  may  use  all  the  fingers  in 
the  form  of  a  cone,  or  the  fist  like  Levret. 

When  the  inversion  is  incomplete,  especially  if  there  is  only  a  simple 
depression,  spontaneous  reduction  may  be  determined  by  exciting 
uterine  contraction,  or  by  introducing  the  hand  into  the  uterine  cavity 
without  detaching  the  placenta  and  especially  without  drawing  on  the 
cord,  which  might  complete  the  inversion;  if  necessary,  the  hand  could 
be  introduced  again  into  the  uterus  and  detach  the  placenta,  the  uterine 
contractions  facilitating  the  detachment  and  expulsion. 

When,  however,  reduction  of  a  less  recent  and  smaller  tumour  is 
attempted,  the  two  opposite  peritoneal  surfaces  of  which  almost  touch, 
it  is  hardly  possible  to  commence  reduction  by  depression  of  the  fundus. 
In  such  cases  the  tumour  should  be  taken  in  the  hand  and,  if  swollen, 
should  be  pressed  so  as  to  let  the  blood  ooze  out,  soften  and  relax  it ; 


INVBESION  451 

the  borders  should  then  be  pressed  by  the  tips  of  the  fingers  around 
the  pedicle,  and  the  portion  of  the  uterus  which  is  continuous  with  the 
vaginal  portion  of  the  cervix  should  be  pushed  back  so  as  to  begin  by 
reducing  the  portion  nearest  the  orifice,  i.  e.  the  part  inverted  last,  as 
in  reducing  a  hernia. 

When  reduction  has  not  been  made  during  the  first  few  days  there 
is  no  reason  to  despair  of  efi'ectiug  it  after  several  months  or  even 
years.  I  have  succeeded  in  reducing  an  inversion  of  ten  months ;  ^ 
Sims^  has  reduced  one  of  a  year,  so,  too,  has  West  j^  Barrier*  one  of 
fifteen  months  as  also  White^  of  Buffalo;  Teale^  one  of  two  and  a  half 
years  ;  BockenthaP  one  of  six  years;  Tyler  Smith ^  another  of  twelve 
years;  and  Noeggerath  of  New  York  one  of  thirteen  years. 

2.  In  complete  and  chronic  inversion  the  real  obstacles  to  reduction 
are :  the  contraction  and  hardness  of  the  uterine  tissue,  the  constriction 
and  rigidity  of  the  cervix,  the  mobility  of  the  uterus,  and  especially 
the  defective  fixity  of  the  cervix. 

There  is  a  great  difference  between  the  cases  in  which  the  uterus  re- 
mains soft,  probably  from  arrested  involution,  and  those  in  which  it  is 
hard,  owing  to  involution  having  taken  place  as  usual,  as  is  proved  in 
the  cases  of  several  patients  as  well  as  in  anatomo-  pathological  prepara- 
tions. Eeduction  is  as  difficult  in  the  latter  case  as  it  is  easy  in  the 
former.  Even  when  it  has  come  back  to  its  normal  size  the  inverted 
uterus  still  preserves  a  certain  flexibility.  But  it  is  very  difficult  to 
maintain  this  necessary  flexibility ;  for  in  spite  of  ansesthesia,  it  soon 
contracts  under  the  influence  of  pressure.  After  some  attempts  at 
reduction  it  diminishes  in  size  and  hardens  like  an  apple,  making 
further  efforts  useless.  This  latter  difficulty  is  very  serious,  and  can 
only  be  avoided  by  shortening  the  operation  and  using  all  possible 
means  to  facilitate  it,  stopping  as  soon  as  the  uterus  begins  to  contract, 
and  making  fresh  attempts  after  some  days  of  rest;  or  else  by  proceed- 
ing very  slowly,  determining,  in  imitation  of  nature,  a  gradual  dilata- 
tion of  the  cervix  sufficient  to  allow  of  the  reduction  of  the  organ. 

Hence  two  methods :  a,  the  natural  one,  by  slow  and  continuous 
means;  h,  the  artificial  one,  by  rapid  taxis.  There  is  no  doubt  that 
when  the  patient  can  support  intra-vaginal  pressure  of  the  uterus  it  is 
wise  to  adopt  Tyler  Smith's  ^  plan,  which  has  been  followed  by  Teale,^^ 

'  Acad,  cle  med.,  March,  1863. 

^  Sims,  op.  cit.,  p.  135. 

3  West,  op.  cit.,  p.  228. 

■*  Bulletin  de  I'Acad.  de  med.,  April,  1852. 

^  Atnerican  Journal  of  Medical  Science,  July,  1858. — Report  of  the  Inver- 
sion of  the  Uterus,  by  Dr.  Quakenbusch  {Transact,  of  Med.  Stat,  of  New 
York,  1859,  p.  170).  Unfortunately  the  patient  died  of  peritonitis  sixteen 
days  afterwards. 

«  Medical  Times,  August  20,  1859. 

^  Zcitschr.filr  Gebiirtslc.,!^^.  xv,  S.  318. 

8  Med.-Chirurg.  Transact.,  xli,  183. 

^  Medical  Times  and  Gazette,  April  24,  1858. — I  have  lately  had  a  similar 
case  {Inversion  uterine  de  quatre  mois,  reduction  spontance,  aprvs  oize  jours 
de  compression  par  le  pcssaire  a  air  splwrique  de  caoutchouc),  described  in  a 
paper  presented  to  the  Academy  of  Medicine  in  July,  1878. 

'»  Medical  Times,  August  26tli,  1859. 


452 


UTERmE  DISEASES  IN   DETAIL 


West/  Bockenthal/  and  myself  in  several  cases,  which  consists  iu 
leaving  in  the  vagina  one  of  Gariel^s  air  pessaries  applied  close  to  the 
uterus  by  the  pressure  which  a  T  bandage  exercises  on  it  by  means  of 
a  graduated  compress  placed  on  a  level  with  the  vulva.  I  have  cured 
several  patients  in  this  way,  and  have  seen  others  cured  by  physicians 
to  whom  I  recommended  it.  The  continued  pressure  exercised  by  this 
pessary  on  the  inverted  uterus,  and  through  it  on  the  cervix,  deter- 
mines on  the  latter  organ  an  analogous  effect  to  that  produced  by 
pressure  of  the  foetal  head  or  by  a  polypus  forced  by  the  contractions 
of  the  body  towards  the  cervix,  i.e.  the  slow  and  gradual  dilatation  of 
the  OS,  the  softening  of  the  cervical  ring  and  its  disappearance  so  far 
as  to  allow  of  the  passage  of  the  tumour  produced  by  inversion  through 
this  orifice  and  so  of  spontaneous  reduction. 

When  pressure  causes  uterine  contractions  patients  experience  in- 
termittent pain  of  the  nature  of  labour  pains.  In  such  cases  we  should 
try,  morning  aud  evening,  to  push  back  the  uterus,  seizing  if  possible 
the  moment  when  the  contractile  cervical  ring  is  sufBciently  dilatable 
to  allow  the  body  to  pass  through.  Unfortunately  all  patients  cannot 
bear  this  continued  pressure.  In  one  case  of  inversion  of  seven  and  a 
half  months  the  pressure  of  the  pessary  maintained  for  twelve  days  by 
West  not  only  did  not  replace  the  uterus,  but  caused  peritonitis,  which 
ended  fatally  four  days  after  the  removal  of  the  pessary. 

b.  Artificial  method  hy  rapid  taxis. — To  attempt  to  perform  rapid 
reduction  without  fixing  the  uterus,  by  persistently  pushing  back  this 


Fig.  307. — Gariel's  pessary  in  the  vagina,  to  compress  the  inverted  uterus  and 
so  cause  spontaneous  reduction,     tr,  uterus  ;  p,  Gariel's  pessary  ;  v,  bladder. 

organ  into  the  abdominal  cavity  and  exposing  the  vagina  to  unlimited 
distension,  is  to  run  the  risk  of  lacerating  this  or  other  internal  organs 

1  Medical  Times  and  Gazette,  October  29,  1859. 

2  Ecduction  after  six  years,  Deutsche  Klinih  and   Bulletin   de  therapeu- 
tique,  1860. 


INVERRIONT  ■  453 

dangerously,  and  of  causing  fatal  accidents.  This  is  what  happened 
to  White  of  Buffalo  who  reduced  in  five  minutes  under  chloroform 
an  inversion  which  had  existed  for  fifteen  months,  but  the  patient, 
who  was  thirty-two  years  old,  died  of  peritonitis  sixteen  days  after- 
wards. 

The  rule  of  fixing  the  uterus  by  exercising  counter-pressure  on  the 
hypogastrium  whilst  the  organ  is  pushed  back  is  inapplicable  on 
account  of  the  extensibility  and  defective  resistance  of  the  vagina. 
Aran's  idea  of  the  cervical  lips  when  kept  in  place  by  Museux's 
forceps  or  tenaculum  hooks  being  firm  enough  to  support  reduction 
without  being  torn  is  absurd.  Trying  to  obtain  a  point  d'appui  by 
pushing  the  cervix  back  against  the  sacrum,  as  Barrier  of  Lyons  did, 
is  to  run  the  risk  of  feeling  the  organ  glide  on  this  inclined  plane,  and 
so  elude  reduction.  And  to  retain  the  cervix  between  two  fingers 
introduced  into  the  vagina  whilst  a  third  pushes  the  fundus,  is  to 
narrow  the  isthmus  which  we  wish  to  enlarge  by  pushing  back  the 
fundus,  which  cannot  enter  the  cervix  like  a  wedge  till  the  latter  is 
freed  from  the  pressure  put  on  it.  I  have  tried  all  these  means  and 
have  found  them  defective. 

Therefore  when  the  cervix  is  not  dilatable  (in  spite  of  belladonna  or 
atropine  applications)  attempts  to  reduce  according  to  the  preceding 
rules  will  be  more  likely  to  fail  than  to  succeed,  even  when  the  tissue 
of  the  body  of  the  organ  has  preserved  flexibility  enough  to  be  turned 
back. 

Incision  may  therefore  be  necessary  in  effecting  reduction.  Obser- 
vation has  proved  to  me  that  it  is  practicable,  and  that  it  may  be  done 
without  danger.  I  do  not  mean  that  it  is  always  indispensable,  nor 
that  taxis  should  never  be  attempted  without  incision.  When  neces- 
sary, longitudinal  incisions  should  be  made,  commencing  from  the 
cervix  and  extending  along  the  neck^  so  as  to  divide  the  circular  fibres 
of  the  isthmus ;  it  is  best  to  make  two  or  more,  some  in  front  and 
others  behind.^ 

As  to  the  fixity  of  the  cervix,  whilst  adopting  Barrier's  precept  to 
direct  this  part  of  the  uterus  towards  the  sacrum,  I  think  this  means 
of  immobilisation  insufficient.  Therefore,  in  lecturing  on  taxis  as 
applied  to  uterine  inversion  I  have  for  many  years  insisted  on  the 
necessity  of  keeping  the  cervix  fixed  with  two  fingers  introduced  into  the 
rectum,  and  have  laid  down  the  following  rules  with  regard  to  the 
operation.  To  seize  the  cervix  the  operator  must  necessarily  first  draw 
it  outside  the  vulva  with  Museux's  forceps.  Immediately  afterwards  he 
introduces  the  index  and  middle  finger  of  the  left  hand  into  the 
rectum  above  the  uterus,  and  by  bending  them  forwards  the  cervix  is 
easily  fixed  through  the  rectal  wall ;  then  seizing  the  uterus  with  the 

'  As  a  rule  I  increase  the  number  and  diminish  the  deptli.  I  cannot  agree 
with  Barnes  (op.  cit.,  p.  038)  as  to  the  depth  of  the  incisions  whicli  he  recom- 
mends. Peritonitis,  although  not  common,  is  to  be  feared.  Besides  this  danger, 
there  is  that  of  h:emorr]iage ;  Gaillard  Tliomas  gives  an  example.  I  also 
prefer  making  incisions  before  and  behind  ratlicr  than  laterally,  as  less  likely 
to  endanger  the  opening  of  arteries  of  any  considerable  size. 


454  "UTERINE    DISEASES    IN    DETAIL 

right  hand  he  pushes  it  back  into  the  vagina,  still  keeping  the  neck 
hooked  down  by  the  fingers  of  the  left  hand,  and  swings  it  round  so 
that  the  fundus  of  the  organ  contained  in  the  palm  of  the  right  hand 
is  turned  towards  the  pubis,  in  place  of  towards  the  rectum,  the  cervix 
being  directed  towards  the  sacrum  and  retained  on  this  side  by  the 
fingers  of  the  left  hand.  These  fingers  hold  the  cervical  portion  of 
the  uterus  through  the  rectal  wall,  and,  by  separating,  they  press 
strongly  into  the  angular  sinuses  which  the  utero-sacral  ligaments 
form  on  each  side  by  their  insertions  right  and  left  of  the  postero- 
lateral surface  of  the  cervix ;  we  feel  these  ligaments  stretched  like  two 
guitar  strings.  Then  with  the  thumb  and  index  finger  of  the  right 
hand  pressure  is  exercised  on  the  pedicle  of  the  tumour^  so  as 
gradually  to  increase  the  depth  of  the  utero-cervical  groove,  and  by 
uniting  efforts  of  taxis  on  the  body  with  those  of  retention  or  immobi- 
lisation of  the  neck,  reduction  of  the  uterus  is  gradually  effected  with- 
out violence  in  a  few  minutes. 

In  reduction  two  phases  may  be  distinguished :  the  first,  which 
consists  in  bringing  the  body  of  the  uterus  up  into  the  cervix;  the 
second,  in  forcing  the  fundus  to  pass  through  the  os  internum.  The 
first  is  accomplished  by  pushing  the  body  of  the  uterus  upwards, 
whether  the  neck  is  retained  through  the  rectum  or  whether  the  vagina 
is  stretched  so  as  to  force  the  orifice  to  open  first  and  the  neck  after- 
wards. The  second  is  effected  more  easily  by  compressing  the  fundus 
laterally,  and  by  thrusting  the  thumb  into  a  horn  of  the  uterus,  which 
makes  one  half  of  the  organ  slip  through  the  os  internum  instead  of  the 
entire  fundus,  which  presents  a  much  larger  diameter. 

When  inversion  cannot  be  reduced  by  any  of  these  methods  should 
that  of  Thomas^  of  New  York  be  tried?  It  consists  in  making  an 
incision  in  the  centre  of  the  abdominal  wall,  introducing  dilating 
forceps  into  the  inverted  cervix,  and  when  dilatation  is  completed  re- 
ducing the  uterus  by  means  of  the  other  hand  introduced  into  the 
vagina.  Thomas  has  succeeded  in  a  patient  twenty-three  years  old; 
still  I  could  not  venture  to  recommend  his  method. 

I  have  applied  my  method  of  reduction  in  the  case  of  a  young  lady 
who  had  sufl'ered  from  uterine  inversion  for  ten  months,  and  who  was 
greatly  exhausted  owing  to  repeated  heemorrhage.  Success  was  rapid, 
complete  and  lasting;  pregnancy  followed.  Unfortunately  an  abnormal 
insertion  of  the  placenta  in  the  cervix  caused  repeated  haemorrhage 
and  premature  delivery  at  the  seventh  month;  inversion  was  not  re- 
produced. In  another,  delivered  three  weeks  previously,  my  method 
of  taxis  led  immediately  to  a  radical  cure.  In  another  of  my  patients, 
cured  by  the  same  method,  after  vain  attempts  had  been  made  by 
elastic  compression,  two  pregnancies  occurred  followed  by  natural 
delivery,  proving  the  permanency  of  the  cure.  Tyler  Smithes  patient 
has  had  several  children  since  the  operation.  Another  complete  inver- 
sion occurred  after  the  first  labour  which  followed  reduction,  but  it 

^  American  Journal  of  Obstetrics,  Nov.,  1869. —  Union  medicale,  11  Jan., 
1870.  Henry  Miller,  Thoughts  of  Chronic  Inversion  of  the  Uterus.  Loiiis- 
ville,  1870. 


INVEESION 


455 


was  reduced  immediately  without  any  difficulty.  A  patient  in  whom 
Marion  Sims  effected  reduction  after  a  year  was  also  fortunate  enough 
to  have  another  pregnancy.  Reduction  therefore  restores  to  the  organ 
all  its  functions. 

In  quite  recent  inversion  occurring  after  delivery  the  fundus  of  the 
uterus  may  suddenly  enter  through  the  cervix  under  the  influence  of 


Fig.  308. — Pcsition  of  the  two  hands  in  reducing  uterine  inversion  by  my 
method  :  the  two  fingers  of  the  left  hand  are  curved  to  retain  the  cervix, 
the  fingers  of  the  right  hand  push  back  the  utenis,  commencing  with  the 
parts  which  have  escaped  last.  It  will  be  seen  that  the  utero-sacral  liga- 
ments are  exaggerated,  and  that  the  bladder  has  been  left  in  its  usual  place. 

taxis,  as  an  india-rubber  ball  would  do  that  was  turned  on  itself.  In 
cases  of  chronic  inversion,  on  the  contrary,  reduction  is  effected  slowly. 

The  proofs  of  success  after  operation  are  the  following  :  appearance 
of  the  uterine  tumour  at  the  hypogastrium ;  disajjpearance  of  the 
pelvic  and  vaginal  tumour;  the  presence  at  the  further  end  of  the 
vagina  of  the  cervical  os,  broad  and  open,  leading  into  the  uterine 
cavity ;  the  introduction  of  a  finger,  or  at  least  of  the  sound,  into  the 
cavity,  in  order  to  be  sure  that  reduction  is  complete. 

However  successful  the  operation  may  have  been,  reduction  requires 
to  be  maintained.  The  hand  or  finger  should  remain  for  some  minutes 
in  the  uterus  to  support  the  walls  and  excite  contractions.  The 
patient  should  be  advised  to  remain  in  the  dorsal  decubitus,  the  pelvis 
higher  than  the  trunk,  and  especially  to  avoid  efforts  in  defecation  and 
micturition.  Vaginal  injections  should  be  made  and  cold  fomentations 
applied,  while  rest  should  be  ensured  by  sedatives  and  antispasmodics. 
Lastly,  stimulants  should  be  administered  in  cases  of  inertia,  especially 


456  UTERINE   DISEASES    IN    DETAIL 

ergot  when  the  uterine  globus  does  not  form  and  harden.  !Purther 
precautions  will  be  dictated  by  circumstances,  and  modified  according 
to  the  various  accidents  which  may  arise.  It  must  not,  however,  be 
forgotten  that  inversion  may  be  reproduced.  Leblanc  of  Orleans 
mentions  a  case  of  inversion  reduced  immediately  after  delivery  which 
was  reproduced  ten  days  afterwards  accompanied  by  acute  colics  and 
hsemorrhage,  and  which  was  reduced  with  difficulty. 

II.  When  reduction  is  impossible  we  must  guard  against  accidents, 
especially  hsemorrhage,  so  as  to  make  inversion  bearable,  or  else  ex- 
tirpate the  uterus  in  order  to  put  a  stop  to  serious  accidents.  In  the 
former  case  palliative  treatment  is  adopted ;  in  the  latter  radical  cure 
is  attempted. 

1.  Palliative  treatment  should  always  be  preferred  on  account  of 
the  risk  attending  radical  cure  by  amputation  of  the  uterus.  If  the 
pain  is  moderate,  if  hsemorrhage  is  easily  arrested,  if  there  is  not  much 
purulent  leucorrhoea,  if  the  patient  can  walk  and  take  a  necessary 
amount  of  exercise,  and  especially  if  the  menopause  is  near  at  hand, 
palliative  treatment  only  should  be  resorted  to,  such  as  means  of  re- 
tention, tonics,  general  and  local  hsemostatics,  more  or  less  powerful 
modifications  of  the  uterine  mucous  membrane.  A  perinseal  pad  re- 
tained by  a  T  bandage  and  attached  to  a  good  belt  may  be  of  great 
use  by  supporting  the  uterus  in  the  vagina  and  preventing  painful 
dragging.  Tonics  are  almost  always  necessary,  owing  to  the  debility 
occasioned  by  repeated  hsemorrhage.  Generous  diet,  country  life,  a 
great  deal  of  time  spent  on  the  sofa  in  the  open  air,  are  the  best  means 
which  can  be  used.  Haemostatics,  which  are  even  indicated  in  the 
intercalary  period,  become  indispensable  when  hsemorrhage  occurs. 
The  horizontal  decubitus  with  flexion  of  the  limbs,  cold  vaginal  injec- 
tions, ice  applied  to  the  hypogastrium,  to  the  internal  and  upper  part 
of  the  thighs,  and  even  to  the  vagina,  perchloride  of  iron  administered 
internally  and  locally,  dilute  sulphuric  acid,  ergot :  such  are  the  most 
important  medicaments  to  be  used  in  palliative  treatment. 

Lastly,  we  may  try  to  modify  the  uterine  mucous  membrane  by 
thickening  the  epidermis,  transforming  it  into  a  cicatricial,  hard,  re- 
tractile tissue,  capable  of  opposing  a  barrier  to  hsemorrhage,  and 
reducing  the  size  of  the  tumour  gradually.  In  place  of  applying 
perchloride  of  iron  to  this  surface  various  caustics  may  be  used, 
such  as  the  mineral  acids,  Yienna  paste,  Canquoin  caustic,  or  the 
actual  cautery.  Aran^  recommends  chloride  of  zinc  in  the  form  of 
Canquoin  plaster  so  as  gradually  to  reduce  the  inverted  uterus  to  a 
kind  of  stump.  I  have  tried  to  obtain  the  same  effect  from  the 
actual  cautery,  but  though  I  have  applied  it  at  white  heat  fourteen 
times  I  have  never  succeeded  in  destroying  the  mucous  membrane 
which  was  always  renewed.  Ploret,^  who  appUed  chloride  of  zinc 
to  an  irreducible  inversion,  taking  care  to  maintain  Canquoin  plaster 
on  the  uterus  by  means  of  a  stem  with  a  cup  like  extremity,  to 
prevent  the  caustic  from  being  displaced  and  destroying  the  vagina, 

'  Op.  cit.,  p.  909. 

2  Documents  chirurgicaux,  p.  168.     Paris  and  Lyons,  1861. 


INVERSION  457 

found  that,  under  the  combined  influence  of  cauterisation  and  pressure 
at  the  culminating  point  of  the  tumour,  the  latter  became  gradually 
depressed  till  the  inversion  was  reduced.  This  result  is  evidently 
exceptional. 

2.  Badical  cure  or  extirpation  of  the  irreducible  uterus  was  till  a  few 
years  ago  thought  to  be  an  unjustifiable  operation.  Boyer^  prescribed 
amputation  as  well  as  ligature.  The  bad  results  which  have  generally 
followed  ablation  of  the  uterus  in  cases  of  organic  lesion  have 
induced  the  majority  of  French  surgeons  to  condemn  the  operation. 
I  think,  however,  that  the  recent  progress  made  by  surgery  in  this 
direction,  showing  the  possibility  of  removing  the  uterus  as  well  as 
the  ovaries  by  abdominal  section,  justifies  the  assertion  that  ablation 
of  the  inverted  uterus  by  the  vagina  (a  much  less  dangerous  ope- 
ration) should  not  be  condemned  without  appeal.  Not  only  has 
it  been  proved  by  numerous  examples,  that  life  is  compatible  with 
the  loss  of  the  uterus  destroyed  by  spontaneous  gangrene,  but  facts 
also  show  that  the  extirpation  of  the  inverted  uterus  is  not  a  more 
dangerous  operation  than  the  majority  of  those  undergone  by  patients 
affected  with  lesions  comparable  to  uterine  inversion  in  gravity. 
West^  says  that  out  of  59  cases  in  which  it  has  been  undertaken 
it  has  been  successful  forty-two  times,  Forbes^  and  McClintock*  have 
published  papers  describing  the  best  methods  of  performing  this 
operation. 

Simple  excision  with  a  bistoury,  although  successful  once  in  the 
hands  of  Velpeau,^  is  too  dangerous  to  be  recommended. 

The  ecraseur  seems  to  be  preferable  to  excision,  because  less  liable 
to  cause  haemorrhage.  This  instrument,  however,  ]ed  to  fatal  results 
in  the  hands  of  Aran;^  and  although  successful  in  those  of  McClin- 
tock'''  and  Sims,^  I  think  it  is  too  dangerous  to  be  recommended 
even  when  used  as  suggested  by  Denuce,  who  made  "the  section  in 
twenty-four,  thirty- six  or  forty-eight  hours,  and  who  was  successful 
with  one  patient.  Hsemorrhage  is  not  the  only  danger  attending  the 
operation.  The  opening  of  the  peritoneal  cavity,  the  excruciating 
pain  produced  by  strangulation  of  the  organ  which  has  a  tendency 
to  produce  peritonitis,  are  reasons  for  making  us  condemn  the 
ecraseur  almost  as  much  as  excision.  Excision  immediately  preceded 
by  the  application  of  a  ligature^  is  less  dangerous  than  simple  excision, 
or  even  ecrasement,  owing  to  the  occlusion  of  the  abdominal  cavity 

'  Traite  des  ^maladies  chirurgicales,  t.  x,  p.  510.     Paris,  1825. 

2  Op.  cit.,  p.  230. 

^  Op.  cit. :  out  of  36  cases,  26  were  treated  by  ligature  (21  cures),  2  by 
excision  (1  cure),  8  by  ligature  and  excision  (5  cures). 

■*  Op.  cit.  :  3  cases  of  extirpation  of  tlie  uterus  witb  success  :  1  by  ligature, 
1  by  ligature  and  the  ecraseur,  1  by  ligature  and  excision. 

•''  Clinique  chirurgicale,  t.  ii,  p.  461. 

«  Op.  cit.,  p.  914. 

7  Op.  cit.,  p.  85  ;  it  sliould  be  remarked  that  the  patient  was  seventy  years 


old. 


Op.  cit.,  p.  135  ;  the  patient  was  thirty-nine. 

English  surgeons  have  performed  the  operation  with  the  bistoury  or  strong 


458  UTEBINE    DISEASES    IN    DETAIL 

determined  by  ligature,  the  rapidity  of  the  operation,  the  probable 
cessation  of  strangulation  from  the  suppression  of  the  tumour  situated 
below  the  ligature,  and  from  the  absence  of  hsemorrhage  which  con- 
striction seems  to  prevent.  I  do  not,  however,  like  the  latter  mode 
of  operation,  because  the  rapidity  of  the  operation  does  not  admit  of 
adhesions  being  estabhshed  to  close  the  peritoneal  cavity. 

Excision  immediately  preceded  by  the  application  of  a  cautery 
clamp  on  the  pedicle  of  the  tumour^  would  be  more  efGcacious  in 
provoking  the  formation  of  these  adhesions  and  so  preventing  peritoneal 
accidents.  But  I  should  fear  that  it  would  not  always  prevent  the  de- 
velopment of  accidents  characteristic  of  strangulation. 

I  greatly  prefer  excision  by  the  actual  cautery  performed  slowly  and 
at  several  sittings.  I  have  performed  the  operation  twice  with  great 
success  by  means  of  the  galvano-caustic  wire  applied  for  forty-eight 
hours,  taking  care  to  make  it  red  hot  every  two  hours,  and  to  increase 
the  constriction  after  it  has  cooled,  so  as  only  to  let  it  penetrate  each 
time  to  the  extent  of  the  tissue  destroyed  by  the  fire.  There  is  a  great 
chance  of  obtaining  adhesive  peritonitis  by  this  method,  and  so  avoid- 
ing hffimorrhage.  Having  been  so  successful  in  these  two  cases  I  con- 
sidered the  operation  a  safe  one ;  unfortunately  it  was  not  so  :  in  a 
third  case  nervous  symptoms  manifested  themselves,  apparently  caused 
by  strangulation,  for  which  I  could  not  account,  and  followed  by 
attacks  of  hysteria  and  fatal  cerebral  congestion ;  consequently  I  have 
abandoned  this  method  in  favour  of  the  elastic  ligature  or  of  Paquelin's 
thermo-cautery  with  the  curved  knife,  which  I  have  had  made  for 
excision  of  the  uterus. 

The  application  of  an  elastic  ligature  romid  the  pedicle  of  the  tumour 
with  the  aim  of  destroying  its  vitality  is  a  method  which  presents  more 
advantages  and  fewer  dangers  than  any  other.  Constriction  should  be 
moderate  at  first  till  it  excites  sufficient  inflammation  to  cause  the  ad- 
hesion of  the  adjacent  surfaces  of  the  peritoneum  covering  the  inverted 
organ.  If  pain  or  nervous  symptoms  occur,  as  frequently  happens 
after  the  application  of  the  ecraseur  or  ligatures  when  rapidly  tightened, 
the  ligature  should  be  quickly  relaxed,  when  these  serious  symptoms 
usually  cease.  In  a  short  time  constriction  may  again  be  applied  and 
increased  gradually,  the  organ  being  allowed  a  few  hours'  or  if  neces- 
sary a  few  days'  rest.  Formerly  I  used  a  double  flexible  iron  wire,  the 
two  extremities  of  which  are  passed  through  a  serre-noe^ul,  so  that 
constriction  may  be  maintained  and  increased  gradually ;  catgut  may 
also  be  used,  or  silver  wire  covered  with  silk,  such  as  dentists  use. 

In  one  case  in  which  I  employed  this  method  the  uterus  fell  the 
thirtieth  day,  the  patient  (who  was  only  twenty-three)  having  run  no 
danger  whatever.     In  this  case  the  ligature  did  not  act  as  a  bistoury 

scissors.  Palaspiano  in  one  case  of  inversion  of  six  yeare'  standing  began  with 
a  red-hot  metallic  ligature  ;  he  next  nsed  a  loop  of  wire  which  he  drew  very 
tight,  and  cut  the  uterus  below  with  scissors  ;  he  was  fortunate  enough  to  save 
his  patient.  During  the  next  four  months  there  was  a  sero-sanguineous  dis- 
charge from  the  stump  by  the  vagina. 
^  Valette,  Injon  medical,  April,  1871. 


INVERSION 


459 


or  ecraseur  by  dividing  the  portion  enclosed  in  the  loop,  but  only  by 
causing  ulceration  of  the  part  on  which  constriction  was  exercised,  and 
by  simultaneously  obtaining  the  sloughing  of  the  tumour  and  the 
formation  of  salutary  peritoneal  adhesions.  Care  must  be  taken  to 
maintain  cleanliness  of  the  vagina  by  frequent  detersive  lotions,  so  as 
to  avoid  the  accumulation  of  muco-purulent  and  putrid  discharges. 
The  fall  of  the  tumour  may  be  hastened  at  last  by  rapid  constriction 
of  the  pedicle,  the  adhesions  which  have  been  established  saving  the 
patient  from  the  accidents  to  which  she  would  have  been  exposed  by 
the  premature  use  of  the  bistoury.^ 
Since  then  I  have  employed  the 
elastic  ligature  by  means  of  an 
india-rubber  tube,  tightened  mode- 
rately the  first  day,  and  more  every 
succeeding  day  till  the  tumour  falls, 
which  it  generally  does  from  the 
twelfth  to  the  eighteenth  day.  I 
have  employed  this  mode  of  opera- 
tion twice  ;  one  of  my  pupils  by  my 
advice  used  it  a  third  time.  These 
three  patients  recovered  completely 
without  ever  having  run  any  dan- 
ger. Before  commencing,  it  is  well 
to  make  a  groove  round  the  pedicle 
of  the  tumour  with  the  actual  cau- 
tery or  the  thermo-cautery  for  the 
elastic  ligature,  which  has  the 
double  advantage  of  acting  as  a 
guide  for  the  ligature  and  of  mak- 
ing its  first  application  less  painful. 
The  treatment  of  inversion,  there- 
fore, answers  all  the  indications  :  1, 
for  quite  recent  immersion  artificial 
reduction  by  my  method  (Fig.  310), 


Fig.  309. — Inverted  uterus,  the  abla- 
tion of  which  is  to  be  performed 
by  the  elastic  ligature  ;  c  a,  groove 
of  about  two  or  three  millimetres, 
hollowed  out  all  round  the  pedicle 
on  a  level  with  the  cervix  by  the 
actual  cautery,  to  receive  the  liga- 
ture ;  t  c,  india-rubber  tube ;  n, 
knot  of  wax  thread  fastening  the 
ligature  and  keeping  it  distended 
in  order  to  maintain  constriction. 


the  placenta  being  previously  re- 
moved if  still  adherent;  2,  Later, 
spontaneous  reduction  by  GariePs  pessary  (Fig.  309)  ;  2>,iftheuients 
resists  try  artificial  reduction  by  taxis,  according  to  my  method,  with 
the  help  of  two  fingers  hooked  into  the  rectum,  taxis  always  aided  by 
chloroform,  and,  if  necessary,  by  several  incisions  not  too  deep ;  4, 
if  the  uterus  still  resists  and  if  the  danger  of  exhaustion  from  hamor- 
rhage  becomes  urgent,  ablation  of  the  body  of  the  uterus  by  the  elastic 
ligature  applied  in  a  groove  traced  by  the  thermo-cautery  (Fig.  311). 
A  vaginal  portion  of  the  neck  remains,  differing  in  no  respect  from 
that  seen  in  the  vagina  in  the  normal  condition. 

^  By  adding  my  cases  to  West's  statistics,  we  find  that  out  of  sixty-six  abla- 
tions of  the  inverted  uterus  forty-eiglit  cures  have  been  obtained,  and  propor- 
tionally far  more  cures  by  ligature  than  by  either  of  the  otlier  methods. 


CHAPTER  III 

MOEBID  STATES  WITHOTTT  NEOPLASM — PLTJXION — CONGESTION — ENGOEGEMENT 
— METEITIS  —  OTAEITIS  AND  SALPINGITIS  —  PEEI-UTEEINB  INFLAMMA- 
TION— OF  LEUCOEEH(EA  IN  GENEEAL,  AND  TJTEEINE  CATAEEH  IN  PAETI- 
CULAE — HTPEETEOPHY  AND  ATEOPHT — GEANTJLATIONS  AND  FUNGOSITIES 
^XJLCBEATION   AND  ULCEES  OF  THE   TJTEEINE    CEEVIX 

These  are  maladies  wliich  may  be  caused  by  purely  local  action  or 
by  a  general  and  even  a  diathetic  affection  reacting  more  or  less  on 
the  rest  of  the  organism.  But  they  are  compatible  with  the  preserva- 
tion of  form,  structure  and  texture  of  the  organ,  and  are  neither  accom- 
panied by  the  production  of  new  organic  elements  nor  by  the  formation 
of  any  tumour.  They  answer  to  the  class  of  maladies  designated  under 
the  name  of  vital  affections  as  contrasted  with  organic  lesions. 

The  first  is  only  the  exaggeration  of  a  physiological  condition,  uterine 
fluxion.  Muxion  by  being  repeated  gradually  produces  the  second, 
congestion.  The  reproduction  or  permanence  of  these  two  conditions 
or  of  one  of  them  suffices  to  produce  the  third,  engorgement.  Pluxion 
and  congestion  are  the  usual  if  not  necessary  elements  of  inflammation ^ 
leucorrJma,  Jiypertj-ojiliy ,  granulations,'  fwigosities,  and  ulceration, 
which  ai-e  also  often  connected  with  the  existence  of  a  diathetic  affec- 
tion. There  is  a  sort  of  connection  between  these  morbid  links  owing 
to  the  mutual  influence  which  they  exert  on  each  other.  T^iuxion,  for 
example,  when  repeated  becomes  a  cause  of  congestion.  Engorgement 
is  usually  a  consequence  of  the  repetition  of  morbid  acts  which  keep 
up  these  two  conditions,  rather  than  a  malady  occurring  spontaneously. 
Inflammation,  while  developed  in  a  direct  manner^  hardly  ever  exists 
without  being  kept  up  by  a  congestive  state  or  without  determining 
a  permanent  congestion  of  the  organs  in  which  it  is  located.  Leucor- 
rhoea  produced  by  uterine  catarrh  or  endo-metritis,  is  often  complicated 
by  a  condition  of  inflammation,  fluxion,  congestion  or  engorgement. 
Hypertrophy,  when  not  consecutive  to  inflammation,  is  not  produced 
without  previous  congestion. 

Granulations  and  fungosities,  whilst  sometimes  arising  as  simple 
papillary  hypertrophy  of  the  mucous  membrane,  are  seldom  produced 
without  having  been  preceded  by  more  or  less  extensive  inflammation, 
folliculitis,  uterine  catarrh,  leucorrhoea,  &c.  Lastly,  ulcers  often  offer 
a  combination  of  several  of  the  morbid  states  just  referred  to ;  they 
are  necessarily  accompanied  by  a  secretion,  are  frequently  covered  with 
granulations,  excite  round  them  hypertrophy  of  the  neck  which  is  their 
usual  seat,  and  seldom  last  any  time  without  being  accompanied  by 
inflammation  and  congestion. 


FLUXION  461 


Fluxion 


Uterine  fluxion  {homflnere,  to  flow)  is  the  temporary  accumulation 
of  blood  in  the  uterine  vessels.  This  morbid  condition  is  characterised 
by  a  movement  of  the  blood  towards  the  womb,  and  is  accompanied 
by  symptoms  of  molimen,  analogous  to  those  which  in  some  women 
announce  the  menstrual  period. 

Uterine  fluxion  is  most  frequently  acute;  but  it  may  become  chronic 
by  indefinite  repetition.  Even  in  the  latter  case  the  characteristic 
which  distinguishes  it  from  congestion  is  the  rapidity  of  its  appearance 
and  disappearance.  It  may  be  followed  or  not  by  haemorrhage,  accord- 
ing to  its  intensity,  its  unusual  prolongation,  and  the  seat  towards 
which  it  tends.  It  may  either  affect  the  uterus  alone,  or  the  uterus 
and  appendages  simultaneously,  most  usually  the  latter.  It  disap- 
pears on  the  dead  body ;  in  autopsies  we  constantly  find  the  size  of 
the  uterus  less  than  it  appeared  formerly.  Injection  of  the  tissues, 
tumefaction,  redness  extending  to  the  cervix  and  often  to  the  vagina, 
a  mucous  or  sanguineous  discharge  sometimes  established  as  at  the 
approach  of  menstruation :  such  are  the  immediate  consequences  of 
uterine  fluxion.  The  physiological  fluxion  which  precedes  menstrua-  • 
tion  may  be  taken  as  the  type  of  morbid  fluxion.  The  temporary 
modifications  produced  in  the  organ  by  fluxion  can  readily  be  under- 
stood by  studying  the  uterus  in  women  who  have  died  during  men- 
struation, and  in  whom  the  sudden  suspension  of  life  has  prevented 
the  dissipation  of  the  uterine  plethora  or  congestion  caused  by  fluxion . 
One  of  the  best  proofs  that  fluxion  is  a  different  morbid  state  from 
congestion  is  that  the  best  means  of  treatment  for  the  latter  are,  by  the 
admission  of  all  practitioners,  not  only  the  worst  means  of  treatment 
for  the  former,  but  the  best  means  that  can  be  employed  to  produce 
it.  For  instance,  the  repeated  application  of  leeches  to  the  cervix, 
anus,  labia,  groins,  hypogastrium  and  loins  is  an  efficacious  means  of 
subduing  congestion,  and  disgorging  the  congested  uterus  of  blood; 
on  the  other  hand,  all  practitioners  know  the  tendency  they  have  to 
induce  or  increase  the  menstrual  flux  when  administered  at  the  oppor- 
tune moment,  i.  e.  immediately  before  the  period. 

1  have  seen  with  interest  that  the  existence  of  fluxion  is  not  only 
accepted  by  several  pathologists  who  had  formerly  ignored  it,^  but  also 
that  its  reality  is  placed  beyond  all  doubt  by  Yirchow  in  his  scientific 
researches  on  pathological  anatomy  and  histology.  "The  vessels," 
Billroth^  tells  us,  "  dilate  or  become  distended  when  irritated,  and  are 
disgorged  anew  soon  after  irritation  has  ceased.  It  is  as  easy  to 
observe  the  fact  as  it  is  difficult  to  discover  the  cause.  The  exagge- 
rated afflux  of  blood  is  the  reaction  or  response  of  an  irritated  vascular 

'  Nonat  et  Linas,  Traite  pratique  des  maladies  de  I'uterus,  p.  1C7.  Paris, 
1869. — Revdllout,  Des  Tuvieiirs  Jiuxionnaires  de  I'uterus  {Gazette  des  Iwpitaux, 
1869,  1874). — Jaccoud,  De  la  Congestion,  in  his  work  entitled  Pathologie 
medicale,  t.  i. 

2  j)ie  cdlg.  chirur.  Pathologie  u.  Therapie,  p.  62.     Berlin,  1876. 


462  UTEEINE    DISEASES    IN    DETAIL 

part  to  the  irritation :  ubi  stimulus,  ibi  jiumis.  The  names  active 
hypereemia^  active  congestion,  which  have  been  employed  to  designate 
this  afflux  of  blood  do  not  express  the  mode  of  production,  and  Yirchow 
has  rightly  brought  into  use  the  old  ievm  fluxion." 

Diagnosis. — Uterine  fluxion  is  met  with  in  nulliparae  as  in  other 
women ;  it  is  common  amongst  girls,  and  in  them  seems  to  be  pro- 
duced by  difficulty  in  the  estabhshment  of  menstruation.  The  cli- 
macteric is  also  marked  by  the  appearance  of  irregular  uterine  fluxions 
and  hsemorrhages. 

Subjective  signs. — Heavy  dull  pain  developed  rapidly  in  the  lumbo- 
sacral region,  intra-pelvic  weight,  a  feeling  of  internal  fulness  and  heat : 
such  are  the  local  symptoms  in  the  beginning.  If  the  fluxion  con- 
tinues there  are  dull  colics  in  the  sides,  umbilicus,  and  hypogastrium, 
returning  momentarily,  or  even  periodically  in  the  form  of  spasms. 
If  the  afflux  of  blood  increases  the  symptoms  become  more  marked; 
the  patient  experiences  the  sensation  of  a  weight,  as  well  as  discomfort 
which  seems  to  be  produced  by  a  large  foreign  body,  a  burning  heat 
in  the  pelvis,  dragging  in  the  loins  and  groins,  acute  colics,  deep  pelvic 
pulsations  synchronous  with  those  of  the  pulse.  At  this  stage  there 
is  often  great  difficulty  in  sitting,  standing,  walking,  &c.  In  the  most 
serious  cases  the  internal  heat  felt  in  the  abdomen  is  constant  and  in- 
creases at  intervals,  extending  from  this  point,  as  from  a  centre, 
towards  the  umbilicus,  and  more  frequently  along  the  anterior  portion 
of  the  thighs  to  the  knees.  This  burning  heat  is  coincident  with 
irritation  of  the  vulva,  frequent  desire  for  micturition  accompanied  by 
a  burning  sensation,  which  is  sometimes  so  acute  as  to  force  tears  ; 
the  urine  is  passed  in  small  quantity  always  loaded  with  urates  or 
phosphates,  and  sometimes  containing  more  or  less  mucus.  Consti- 
pation is  sometimes  very  obstinate.  Occasionally,  when  the  fluxionary 
movements  are  exaggerated  the  motions  are  accompanied  by  mucous 
excretions  forming  a  kind  of  membrane.  At  other  times  there  are 
diarrhceic  evacuations  somewhat  like  those  of  dysentery,  or  it  may 
be  that  only  at  intervals  there  .is  an  unnaturally  frequent  and  very 
painful  desire  to  pass  urine  and  go  to  stool. 

General  symptoms  precede  and  accompany  these  local  symptoms. 
Those  which  precede  them  are  the  special  phenomena  indicating  an 
afflux  of  blood  towards  the  uterine  economy,  with  symptoms  of 
molimen  more  marked  than  the  prodromata  of  menstruation; 
shivering,  spasm,  vague  nervous  phenomena,  irritability,  and  a  tendency 
to  tears.  Those  which  accompany  them  are  phenomena  of  reaction, 
showing  that  the  organism  shares  the  sufferings  of  the  uterus ;  nervous 
erethism,  circumscribed  pains,  neuralgia,  gastralgia,  migraine,  dys- 
pepsia, vomiting;  in  fact  when  fluxion  occurs  frequently,  or  when  it 
lasts  for  some  time,  the  phenomena  of  fluxion  observed  in  the  pelvic 
organs  are  repeated  in  the  most  important  organs  of  the  economy,  the 
heart,  lungs,  brain,  &c. 

Objective  symptoms. — The  hypogastrium  is  enlarged,  moderately 
warm,  only  slightly  painful,  but  sensitive  to  pressure.  The  vagina  is 
usually  warm  and  moist,   sometimes  the  seat  of  abundant  leucorrhoea. 


FLUXION  463 

The  uterus  is  larger^  heavier,  less  mobile,  considerably  lower  and  in- 
clined forwards,  slightly  painful  to  pressure,  or  at  least  to  movements 
directly  conveyed  to  it  or  transmitted  through  the  body.  The  size  of 
the  uterus  is  variable,  a  symptom  which  distinguishes  fluxion  from 
congestion.  In  some  cases  tumefaction  is  rapid.  In  women  recently 
delivered  it  may  become  enormous  in  a  few  hours,  passing  the  brim. 
The  body  spreads  out  above  the  neck,  projecting  beyond  it  like  a 
bladder,  a  proof  that  in  fluxion  as  in  congestion  it  is  the  body  rather 
than  the  neck  that  is  affected. 

Usually  the  vagina  and  vulva  participate  in  the  fluxionary  move- 
ment, presenting  a  violet  or  dark  red  colour.  Afflux  of  blood  may 
also  take  place  towards  the  most  important  organs  of  the  economy ; 
these  symptoms  also  distinguish  fluxion  from  congestion.  According 
to  the  seat  of  the  localisation,  they  produce  troubles  characterised  by- 
flushing  of  the  face,  giddiness,  syncope,  cardiac  pain,  a  feeling  of 
suffocation,  epigastric  constriction,  &c.,  alternating  with  the  uterine 
phenomena  or  accompanying  them.  These  uterine  or  visceral  fluxions 
when  chronic  are  often  followed  by  hsemorrhage,  which  however  is  rare 
in  acute  fluxion.  It  at  first  takes  the  form  of  menorrhagia,  coinciding 
with  more  marked  fluxionary  symptoms.  Menstruation  soon  becomes 
deranged  and  advances  a  few  days,  a  week,  then  a  fortnight,  and  as  it 
also  lasts  longer,  patients  end  by  losing  blood  continually. 

The  hEemorrhage  may  gradually  diminish  so  that  patients  may  think 
they  have  got  rid  of  it ;  but  the  least  effort,  fatigue,  travelling,  or  ex- 
cessive intercourse,  bring  it  back  more  violently  than  ever,  together 
with  other  visceral  haemorrhages,  which  gradually  produce  aneemia. 

Treatment. — lluxion  is  always  serious,  even  in  the  simplest  form  and 
in  the  acute  stage,  because  it  shows  a  special  tendency  of  the  uterus  to 
become  the  terminal  point  of  sanguineous  raptus  ;  but  when  it  becomes 
habitual  it  demands  still  more  attention  from  the  physician,  because  the 
uterus  is  apt  to  become  congested  and  hypertrophied ;  because  it  gives 
rise  to  hsemorrhages  producing  angemia,  and  sometimes  to  leucorrhoea, 
throwing  women  into  a  deplorable  state  of  weakness ;  lastly,  because 
owing  to  this  abnormal  activity  of  circulation,  there  is  a  tendency 
to  the  development  of  morbid  products  within  the  substance  of  the 
uterus. 

As  for  the  indications  to  be  fulfilled,  we  must  first  discover  whether 
the  uterine  fluxion  is  secondary,  that  is,  whether  it  is  caused  by  an 
alteration  of  the  uterus  or  its  appendages,  or  whether,  on  the  con- 
trary, it  is  primary,  as  is  usually  the  case.  We  must  then  take  into 
account  the  circumstances  determining  it  either  during  menstruation 
or  in  the  intercalary  period  or  after  delivery  or  abortion.  These  circum- 
stances are :  premature  or  excessive  intercourse,  falls  on  the  seat, 
mechanical  action  of  all  kinds,  overfatigue,  cold,  moral  excitement, 
especially  when  of  a  sad  nature,  &c.  Acute  fluxion  must  also  be 
distinguished  from  chronic;  the  former  usually  occurs  in  girls,  the 
latter  may  be  chronic  from  the  commencement,  owing  to  atony  of  the 
constitution,  or  it  may  assume  the  character  of  chronicity  from  the 
repetition  of  the  haiinorrhage  and  the  consequent  anfemia,  or  from 


464  "UTERINE    DISEASES    IN    DETAIL 

defective  nutrition  caused  by  dyspepsia.  Acute  fluxion  becomes 
chronic,  and  fluxions  in  other  organs  follow  as  a  result  of  the  dis- 
order produced  in  the  vascular  system,  which  finally  seems  to  escape 
the  control  of  any  regulating  influence.  The  treatment  of  uterine 
fluxion  ought  to  be  an  application  of  the  methodic  treatment  of 
fluxions  in  general,  the  principles  of  which  I  have  already  laid  down. 
1.  If  fluxion  is  imminent  or  quite  recent,  recourse  should  be  had 
to  revulsives,  e.  g.  bloodletting  from  some  point  more  or  less  distant 
from  the  seat  of  fluxion.  General  bleeding  is  especially  indicated 
when  the  fluxion  depends  on  constitutional  plethora,  or  when  the 
patient  is  in  good  health.  I  have  several  times  drawn  blood  from  the 
arm  in  young  women  affected  with  recent  fluxions,  always  taking  care 
not  to  exceed  the  strength  of  my  patients.  Another  revulsive  recom- 
mended by  Hippocrates,  and  which  is  very  beneficial,  provided  its 
action  is  sustained  for  several  hours  or  even  days,  is  the  application 
of  cupping  glasses  to  the  breasts.  In  delicate  ])atients  cupping  and 
other  cutaneous  revulsives  should  be  preferred  to  blood-letting. 
Sinapisms  applied  to  the  breasts,  the  upper  part  of  the  trunk,  the 
arms,  the  wrists,  and  if  necessary  large  blisters  on  the  arms,  produce 
energetic  and  salutary  revulsion.  I  have  once  seen  the  vomiting 
caused  by  antimony  effect  speedy  revulsion  and  dissipate  a  recent 
uterine  fluxion.  However^  the  shock  produced  bj  the  vomiting  and 
the  debility  caused  by  the  antimony  might  dispose  the  vascular  system 
to  an  irregularity  of  action  favorable  to  the  recurrence  of  the  same 
fluxion. 

Lastly,  we  may  have  recourse  to  intestinal  revulsives,  but  two  im- 
portant conditions  must  be  observed.  The  first  is  only  to  use  them 
after  bloodletting  or  cutaneous  revulsives,  lest  the  concentration  which 
follows  the  action  of  purgatives  should  be  unfavorable.  The  second 
is  to  avoid  drastics  (especially  aloes),  which  congest  the  lower  portion 
of  the  intestine  and  favour  the  development  of  haemorrhoids,  thus 
increasing  the  uterine  fluxion  in  place  of  dissipating  it.  Saline  pur- 
gatives, magnesia,  castor  oil,  should  on  all  accounts  be  preferred. 
Whilst  revulsive  treatment  is  being  employed  the  patient  should  re- 
main in  bed,  the  pelvis  slightly  raised  by  a  hard  pillow,  the  head 
elevated,  the  legs  flexed  on  the  thighs  and  the  thighs  on  the  pelvis. 
Cold  compresses  or  bladders  of  ice  should  be  applied  to  the  abdomen 
and  thighs,  especially  if  fluxion  is  accompanied  by  hseinorrhage. 
It  is  also  useful  to  prescribe  diffusible  stimulants;  48  drops  of  liquid 
ammonia  in  2  ounces  of  syrup  to  be  taken  in  drachm  doses  in  the 
24  hours  in  a  glass  of  orange  water,  or  from  4  to  7  drops  of  acetate 
of  ammonia  given  in  an  aromatic  infusion  and  repeated  3  or  4  times 
a  day. 

2.  If  the  fluxion  is  fixed  in  the  uterus,  revulsives  should  be  pre- 
ceded by  derivatives  with  the  view  of  deviating  the  flow  of  blood 
which  habit  and  length  of  duration  prevent  being  carried  in  another 
direction.  Cupping  glasses  and  leeches  to  the  loins,  groins  and  hypo- 
gastrium  are  the  best  derivatives  in  such  a  case.  Lastly,  when 
fluxionary  movements  are   frequently    renewed,   and  have  produced 


FLUXION  465 

congestion,  it  may  be  advisable  to  treat  the  fluxion  as  a  true  conges- 
tion, by  depletives  and  derivatives  before  resorting  to  revulsives.  In 
such  cases  leeches  may  be  applied  to  the  cervix,  even  in  women  who 
are  apparently  exhausted,  provided  that  tonics  and  generous  diet  are 
prescribed  at  the  same  time. 

Whether  simple  derivatives  are  employed,  or  depletives  and  deriva- 
tives simultaneously,  the  effect  produced  is  to  disgorge  the  uterus  and 
to  deviate  the  flow  of  blood  directed  towards  this  organ.  But  the 
fluxion  although  mobilised  is  not  necessarily  dissipated.  It  is  then 
that  revulsives  should  be  resorted  to.  Bleeding  is  too  weakening  and 
its  action  not  sufficiently  sustained  for  it  to  triumph  over  an  evil 
which  has  taken  root  in  the  economy.  Although  the  fluxion  is 
mobilised,  we  can  only  hope  to  uproot  it  by  the  use  of  means  the 
action  of  which  is  more  continuous  and  energetic.  Therefore  hydro- 
pathy is  the  best  revulsive,  care  being  taken  after  applying  the  douche 
to  warm  the  skin  by  exercise,  or  if  the  patient  is  too  weak  for  that, 
by  stimulating  frictions,  or  a  short  time  spent  in  dry  hot  air;  and 
after  the  douche  has  been  administered  for  two  or  three  minutes  good 
reaction  should  be  determined,  either  by  dry  frictions  or  by  exercise. 
These  means  of  revulsion  repeated  twice  a  day  produce  surprising  re- 
sults in  a  few  weeks.  In  cases  where  the  patient  was  weakened  by 
repeated  haemorrhage,  and  where  the  fluxion  was  directed  alternately 
to  the  uterus  and  other  viscera,  this  means  has  always  seemed  to  me 
heroic.  Hydropathy  is  beneficial  not  only  by  effecting  a  revulsion 
over  the  whole  cutaneous  surface,  but  by  giving  tone  to  the  whole 
organism  and  producing  a  sedative  effect  on  the  nervous  system. 
The  habitual  use  at  table  of  mineral  waters  such  as  those  of  Lamalou, 
Oreza,  Boulou,  or  Vals,  mixed  with  a  little  wine,  is  of  great  service. 
It  must  be  remembered  that,  in  the  treatment  of  long-standing 
fluxions,  those  revulsives  should  be  used  which  strengthen,  not  those 
which  debilitate.  In  proportion  to  the  strength  of  the  organism  and  to 
the  equilibrium  existing  between  its  various  functions  and  between  its 
various  organs,  vrill  be  the  chance  that  the  fluxion  when  once  dissi- 
pated will  neither  resume  its  usual  course  nor  be  directed  towards 
some  other  viscus. 

The  other  indications  to  be  fulfilled  although  secondary  are  im- 
portant. 

Rest,  which  is  necessary  in  the  acute  stage,  may  be  so  also  in  the 
chronic  state  if  walking  causes  pain  and  increases  the  evil.  In  the 
contrary  case,  exercise  in  addition  to  hydropathy  acts  as  one  of  the 
best  tonic  revulsives  and  one  of  the  best  hygienic  means  for  regulating 
the  equilibrium  of  all  the  organs. 

The  bowels  must  be  kept  regular,  as  the  only  means  of  keeping 
up  the  appetite,  facilitating  digestion  and  overcoming  constipation  ; 
the  latter  is  a  dangerous  complication  of  all  uterine  diseases,  but  par- 
ticularly of  fluxion  and  congestion,  which  are  increased  by  it.  There- 
fore laxatives  should  be  employed  in  place  of  purgatives  ;  I  find  gr.  -^ 
of  extract  of  belladonna  with  gr.  2|  of  medical  soap  made  into  a 
pill  and  taken  every  night  very   effectual,  with  a  spoonful  of  castor 

30 


466  UTERINE    DISEASES   IN    DETAIL 

oil  once  a  week,  or  rhubarb  and  magnesia  in  equal  quantities  in  a  cup 
of  acorn  coffee  or  a  glass  of  Hunyadi  Janos  water.  Laxatives  should 
be  given  alternately  with  enemata  of  oil  or  a  solution  of  manna, 
treacle,  or  glycerine,  so  that  the  large  intestine  may  be  emptied. 
Besides  these  two  indications  there  is  a  third  which  may  require  to 
be  fulfilled  :  that  of  cooling  the  uterus  frequently,  either  directly  by 
vaginal  irrigation,  or  by  acting  upon  the  neighbouring  organs  by 
small  enemata  taken  at  bed  time.  Lastly,  the  debility  which  often 
accompanies  the  cessation  of  the  fluxion  involves  the  necessity  of  care 
during  convalescence.  After  the  disappearance  of  acute  symptoms 
patients  recover  slowly  in  proportion  as  menstruation  is  established 
once  more  in  a  regular  manner.  The  return  of  health  is  still  slower 
after  exhaustion  caused  by  chronic  uterine  fluxion. 


Congestion 

Congestion  (from  co7igerere  to  accumulate)  is  the  persistent  accumu- 
lation of  blood  in  the  vessels  and  capillaries  of  the  uterus.  Sometimes 
it  is  the  result  of  simple  fluxion  strong  or  repeated,  sometimes  of  a 
hindrance  in  the  general  circulation.  It  plays  an  important  part  in 
the  majority  of  uterine  diseases  because  of  forming  an  integral  part  of 
the  uterine  functions. 

In  fact  every  menstrual  period  is  composed  of  three  successive  acts  : 
fluxion,  congestion,  hsemorrhage.  Congestion,  whether  the  result  of 
fluxion  or  uterine  erection,  necessarily  precedes  hsemorrhage;  perio- 
dical uterine  congestion  is  therefore  physiological.  When  the  abund- 
ance of  the  menstrual  hsemorrhage  is  proportioned  to  the  intensity  of 
the  uterine  congestion  all  abnormal  symptoms  disappear  with  the 
discharge.  But  if  resolution  is  not  complete,  the  uterus  remains  the 
seat  of  a  congestion  which  increases  every  month,  giving  rise  to  a  per- 
manent morbid  condition  :  chronic  congestion.^ 

It  becomes  morbid  by  becoming  exaggerated,  by  being  prolonged, 
or  by  encountering  diseased  organs. 

The  conditions  producing  congestion  may  be  local  or  general.  The 
local  conditions  are  :  a  vascular  system  excessively  developed,  especially 
the  venous  system  without  valves  and  of  feeble  contractility ;  a  dis- 
position of  muscular  tissue  favouring  stasis  of  blood  in  the  veins  as  in 
all  the  erectile  tissues  ;  the  position  of  the  organ  which  is  low,  pressed 
from  above  downwards  by  the  weight  of  the  abdominal  viscera,  subject 
to  erections  and  to  monthly  congestion  and  hsemorrhage,  as  well  as  to 
increase  of  size,  dilatations  of  the  venous  system,  and  to  enormous 
hypertrophy  at  every  pregnancy. 

The  general  conditions  are  those  which  produce  irregularities  and 
difficulties  in  the  circulation  with  slackening  of  the  blood  current,  such 
as  diseases  of  the  heart,  lungs  and  liver. — Congestion  may  be  idiopathic 
or  symptomatic;  sometimes  it  constitutes  a  simple  morbid  state,  existing 

'  rieury,  Traite  d'hydrotherapie,  des  Congestions  sanguines  chroniques  de 
V uterus,  p.  446.  Paris,  1852. 


CONGESTION  467 

by  itself — primitive  or  idiopathic  congestion,  facilitating  unfortunately 
the  localisation  of  diathetic  affections  on  the  uterus  or  its  appendages ; 
sometimes  it  is  a  consequence  or  complication  of  an  existing  malady — 
secondary  or  symptomatic  congestion.  It  may  also  be  active  or 
passive.  The  active  form,  due  to  the  persistence  of  the  fluxionary 
movements,  is  a  result  of  the  constant  afflux  of  blood  and  of  the  dis- 
tension of  the  vessels  in  an  organ  which  never  empties  ;  the  passive  is 
due  to  atony,  to  defective  contractility  of  the  vessels,  which  once  filled 
are  not  emptied,  or  to  the  difficulty  placed  in  the  way  of  the  return  of 
the  blood  owing  to  pressure  or  alteration  of  the  uterine  vascular 
system,  or  to  an  obstacle  in  the  general  circulation.  Both  may  be 
either  acute  or  chronic  :  passive  congestion  is  usually  chronic.  It 
may  present  numerous  varieties,  from  feeble  sanguineous  congestion 
to  hsemorrhagiparous  congestion.  After  death  it  usually  persists,  its 
anatomical  alterations  being  injection,  softening,  flexibility  of  the 
uterine  tissue,  especially  of  the  body ;  dilatation  of  the  vessels,  form- 
ing sinuses,  which  on  section  allow  the  escape  of  black  blood  and  the 
entrance  of  a  director  into  their  orifice ;  red-brown  colour  of  the 
mucous  membrane  of  the  body,  with  swelling  and  thickening,  the  dis- 
semination of  red  points  (so  many  little  clots),  oozing  of  drops  of 
blood  from  the  surface  of  the  mucous  membrane,  especially  on  pres- 
sure, a  violet  colour  of  the  vaginal  surface  of  the  cervix,  contrasting 
with  the  relative  paleness  of  the  mucous  membrane  lining  the  cavity. 
In  the  tubes  and  ovaries  there  are  found  softening,  red-brown  colour, 
tumefaction,  and  sometimes  hypertrophic  thickening ;  sometimes 
uterine  and  even  vaginal  leucorrhoea  with  congestive  coloration  of  the 
upper  portion  of  the  vagina ;  sometimes  also  in  the  Fallopian  tubes 
sanguinolent  or  opaque,  white  or  yellowish  liquid  mucus,  containing 
hardly  more  than  epithelial  cells  ;  sometimes,  lastly,  in  the  thickness 
of  the  broad  ligaments,  dilated  venous  bundles,  resembling  the  pam- 
piniform plexus  in  man,  forming  tumours  of  varying  dimensions, 
attaining  half  the  size  of  the  fist  and  reaching  the  renal  region,  coin- 
ciding with  great  congestion  of  the  uterine  tissue,  and  very  m.arked  in 
aged  women  who  have  succumbed  in  the  midst  of  symptoms  of 
obstruction  of  the  venous,  abdominal  or  general  circulation. 

Diagnosis. — Uterine  congestion  occurs  most  frequently  in  multi- 
parse.  Therefore  we  can  form  a  good  idea  of  several  of  the  alterations 
characterising  it,  not  only  by  examination  of  the  uterus  during  men- 
struation, but  by  autopsies  of  women  recently  delivered ;  it  must  not, 
however,  be  forgotten  that  in  women  who  have  aborted  there  is  in  the 
uterine  tissue,  in  addition  to  the  congestive  state,  the  remains  of  the 
hypertrophy  which  modified  it  during  pregnancy. 

Subjective  signs. — Dull  pain  in  the  lumbar  region,  weight  at  the 
sacrum,  anus  and  perinseum,  a  sensation  of  fulness  in  the  pelvis,  in- 
ternal heat :  such  are  the  first  local  symptoms  of  recent  congestion,  as 
of  fluxion.  What  distinguishes  congestion  from  fluxion  is  the  usual 
absence  of  symptoms  of  molimen  and  sanguineous  rapius,  unless  the 
fluxion  which  has  caused  the  congestion  persists  or  returns  repeatedly. 
It  is  the  same  in  a  number  of  cases  where  congestion  may  be  produced 


468  UTERINE    DISEASES    IN    DETAIL 

without  fluxion  passively  from  defective  tone  or  contraction  of  the 
capillaries,  or  where  it  becomes  passive  after  having  been  active  from 
a  gradual  loss  of  tonicity  in  the  vessels ;  or  where  it  may  be  in  a  sense 
hypostatic  owing  to  some  obstacle  placed  in  the  way  of  the  uterine  or 
general  circulation. 

The  symptoms  of  fulness  persist  in  the  pelvis  with  sensations  of 
dragging  in  the  loins  or  groins,  and  troubles  in  the  neighbourhood ; 
there  is  frequent  desire  for  micturition,  obstinate  constipation  often 
accompanied  by  tenesmus,  irritation  of  the  vesical  and  rectal  mucous 
membranes  with  evacuation  of  more  or  less  considerable  quantities  of 
mucus  accompanying  both  micturition  and  defeecation.  The  lumbar 
pains  increase,  those  of  the  groins  extend  down  the  thighs  to  the  knees, 
in  addition  to  which  there  is  often  in  the  left  iliac  region  or  above  it 
a  fixed  pain  which  seems  to  depend  on  congestion  of  the  left  ovary,  or 
on  the  dragging  which  the  uterus,  when  prolapsed  and  with  its  fundus 
inclined  to  the  right,  may  exercise  on  the  ligaments  of  the  left  side ; 
lastly,  there  is  the  sensation  of  a  large  body  threatening  to  fall,  com- 
pressing the  bladder  and  rectum,  weighing  even  on  the  anus,  and 
seeming  to  make  an  effort  to  pass  the  vulval  orifice.  The  sudden  con- 
traction of  the  abdominal  wall,  and  the  shock  which  follows  it  in 
yawning,  coughing,  or  in  the  expulsion  of  faecal  matter,  &c.,  is  accom- 
panied by  a  painful  sensation  as  if  a  heavy  body  was  falling  out  of  the 
pelvis.  Uterine  congestion  lasts  indefinitely;  nothing  indicates  that  it 
is  cured  spontaneously.  Haemorrhage  is  sometimes  added  to  the  other 
symptoms  as  in  cases  of  fluxion  ;  but  usually  menstruation  occurs  rarely 
and  irregularly,  sometimes  being  altogether  wanting,  although  the 
characteristic  pains  of  molimen  may  be  present ;  sometimes  occurring 
too  frequently,  every  three  weeks,  every  fortnight,  or  every  week,  but 
consisting  of  a  very  small  quantity  of  blood.  This  diminution  in  the 
quantity  of  menstrual  blood  is  characteristic  of  dysmenorrhoeic  conges- 
tion. In  addition  there  are  uterine  colics  and  sometimes  even  a  kind 
of  uterine  tenesmus,  the  consequence  of  expulsive  pains  which  oblige 
patients  to  bend  forwards.  Usually  some  of  the  general  symptoms 
of  uterine  maladies  are  also  produced,  such  as  dyspepsia,  disturbances 
of  nutrition  and  consecutive  nervous  phenomena;  and  later  on,  debility, 
anaemia,  palpitations  of  the  heart,  a  small  dry  nervous  cough,  incapacity 
for  any  exertion,  emaciation,  dry  skin,  with  the  sallow  hue  of  the  face 
and  dull  eyes  characteristic  of  the/aeies  uterina. 

Objective  signs. — Hypogastric  palpation  associated  with  vaginal 
touch  shows  an  increase  of  size  in  the  uterus,  but  of  the  body  more 
than  the  cervix.  The  pain  caused  by  this  examination  is  less  owing 
to  the  sensibility  of  the  uterus  than  to  the  difficulty  which  the  increase 
of  size  puts  in  the  way  of  displacement,  and  to  the  dragging  which 
movements  conveyed  by  the  finger  exercise  on  the  neighbouring  organs, 
the  broad  ligaments,  bladder  and  rectum.  Often  the  uterus  is  pro- 
lapsed so  much  that  the  cervix  rests  on  the  perinseum.  At  the  same 
time  the  natural  anteversion  is  increased.  It  is,  however,  necessary  to 
remark  that  congestion,  which  is  so  common  after  delivery  and  abor- 
tion, at  a  time  when  the  uterus  may  be  found  in  another  position  owing 


CONGESTION  469 

to  the  softness  then  characterising  its  tissue,  only  exaggerates  this 
vicious  position;  and  lateral  inclinations,  retroversions  and  retro- 
flexions may  also  become  exaggerated  by  increased  weight  and  soften- 
ing of  the  tissue  of  the  organ. 


Fia.  310. — Reduction  in  the  size  of  the  uterus  in  the  intercalary  period. 

Congestion  is  often  also  more  localised  than  fluxion.  It  more 
frequently  occupies  the  whole  of  the  organ  than  a  portion  of  it; 
it  may,  however,  unlike  fluxion,  occupy  one  portion  to  the  exclusion 
of  the  other  or  in  a  more  marked  degree,  and  more  frequently  the 
body  than  the  neck,  and  one  wall  more  than  the  other.  The  neck 
may  be  so  much  congested  that  it  cannot  be  embraced  by  any  speculum  ; 
it  may  present  a  dark  red  or  violet  colour,  and  offer  to  the  touch  a 
large  soft  swelling,  with  the  orifice  half  open  and  projecting  outwards 
circularly,  especially  on  a  level  with  the  two  lips  in  multiparse,  giving 
to  the  cervix  the  appearance  of  a  mushroom,  or  of  a  cone  with  the  base 
downwards.  In  the  utero-vaginal  cul-de-sac,  on  one  or  both  sides 
of  the  uterus,  bundles  of  venous  vessels  may  be  felt  gorged  with  blood, 
such  as  are  sometimes  seen  in  the  broad  ligaments  in  old  women  where 
congestion  is  of  long  standing.  Sometimes  a  certain  amount  of  mucus 
is  seen  escaping  from  the  cervix.  The  cavity  is  also  enlarged  as  occurs 
likewise  at  the  time  of  erection  accompanying  menstruation  or  coitus. 
This  can  be  ascertained  by  the  use  of  the  catheter,  which  can  be  moved 
with  great  facility  in  the  uterine  cavity.  This  increase  in  capacity  is 
so  marked  that  it  is  observed  even  in  nulliparse. 

Treatment- — When  uterine  congestion  is  symptomatic  its  cure  is 
subordinate  to  that  of  the  malady  on  which  it  depends.  An  alteration 
of  the  uterus,  a  fibroid  for  example ;  a  disease  of  the  ovary  or  Fallopian 
tube;  a  disease  of  the  bladder  or  rectum;  peritonitis;  chronic  enteritis 
may  keep  up  a  congestive  state  in  the  womb  which  we  may  try  to 
alleviate  but  cannot  hope  to  cure,  until  the  original  malady  which  has 


470 


UTERINE  DISEASES  IN  DETAIL 


gradually  produced  the  uterine  congestion  has  been  cured.    Sometimes 
congestion  complicates  uterine  diseases  without  being  exactly  sympto- 


FiG.  311. — Considerable  increase  in  the  size  of  the  uterus,  either  from  tem- 
porary menstrual  congestion  or  from  morbid  and  permanent  congestion, 
particularly  of  the  body. 

matic.  In  such  cases  it  both  hinders  cure  and  increases  the  diseased 
condition.  Hence  the  necessity  of  treating  the  congestion  with  the 
view  of  lessening  the  disease.  As  for  idiopathic  congestion,  it  weakens 
patients,  disturbs  the  functions  of  the  uterus,  and  disposes  it  to  disor- 
ganisations which  may  result  from  the  localisation  of  the  diathetic 
affections  to  which  the  patient  is  exposed. 

The  capital  indication  therefore  is  to  put  a  stop  to  the  accumulation 
of  blood  in  the  uterine  economy,  to  abstract  blood  from  the  organ  and 
prevent  its  being  filled  anew  by  giving  a  different  direction  to  the  cur- 
rent, whilst  diminution  in  the  size  of  the  uterus  is  hastened  by  the  use 
of  resolvents.  The  best  means  of  abstracting  blood  is  to  apply  leeches 
to  the  cervix.  This  treatment  is  sometimes  followed  by  immediate 
relief  if  applied  according  to  the  rules  I  have  laid  down,  namely,  that 
it  should  be  performed  immediately  after  the  end  of  the  monthly  period, 
and  that  a  sufficient  quantity  of  blood  should  be  drawn  to  produce  real 
depletion  of  the  organ.  The  application  should  be  repeated  the  follow- 
ing day  if  the  quantity  already  drawn  has  been  insufficient,  and  it 
should  be  followed  the  next  day  by  a  purgative  chosen  with  reference 
to  the  constitution  and  temperament  of  the  patient,  season  of  the 
year,  &c. 

The  dysmenorrhoeic  symptoms  of  congestion  may  require  the  use  of 


CONGESTION 


471 


narcotics  as  temporary  palliatives :  gr.  ^  of  extract  of  opium  in  a  pill 
every   six  hours^   or    15   drops  of   laudanum  in  an  enema,  or  gr.  ^ 


Fig.  312. — Hypertrophic  congestion  of  the  cervix  and  os  uteri  in  a  multipara. 

of  extract  of  belladonna  twice  a  day.  Narcotics,  however,  as  a  rule 
are  contra-indicated  in  the  treatment  of  this  disease.  Congestion  being 
in  some  degree  renewed  at  every  monthly  period,  the  same  treatment 
must  be  repeated  for  a  considerable  time ;  leeches  to  the  cervix  after 
menstruation,  purgatives,  rest,  &c.  Usually  three  or  four  applications 
of  leeches  made  three  or  four  months  consecutively  suffice  for  the 
treatment  of  chronic  congestion,  or  an  interval  of  two  months  may  be 
left  between  two  applications.  Often,  however,  I  have  been  obliged 
to  make  a  greater  number;  no  rule  can  be  laid  down.  If  the  men- 
strual haemorrhage  is  abundant  it  is  sufficient  to  administer  a  purga- 
tive once  or  twice  a  few  days  after  menstruation. 

Rest,  baths,  vaginal  irrigations  favour  the  action  of  these  means. 
Above  all  patients  should  be  enjoined  to  give  rest  to  the  organ,  i.e.  to 
interrupt  marital  intercourse ;  for  the  absence  of  acute  pain  and  the 
chronicity  of  the  evil  often  cause  this  precaution  to  be  disregarded  to 
the  injury  of  health  and  the  hindrance  of  treatment. 

If  these  means  are  insufficient  derivation  and  revulsion  should  be 
exercised  by  means  of  blisters,  or  of  frictions  with  croton  oil  or  antimo- 
nial  ointment  on  the  hypogastrium  in  cases  of  acute  and  painful 
congestion ;  and  by  means  of  alkaline  and  sulphur  baths,  dry  friction 
of  the  whole  body,  in  fact  by  hydropathy,  in  the  more  frequent  cases 
of  chronic  congestion,  the  least  painful  form  of  congestion  but  the 
most  difficult  to  cure.  These  means  do  not  act  merely  as  revulsives, 
they  also  favour  the  resolution  of  the  engorgement  which  often  com- 
plicates chronic  congestion.     Hydropathy  in  such  cases  is  very  effec- 


472  UTERINE    DISEASES  IN    DETAIL 

tual  after  leeching,  purgatives  and  irrigations ;  I  mean  general  hydro- 
pathy, the  local  douche  is  always  dangerous. 

Sea  bathing,  tonics,  iron,  and  residence  in  the  country  are  necessary 
when  the  malady  is  quite  chronic,  when  the  patient  is  exhausted  and 
ansemicj  and  when  she  has  rested  sufficiently  long  to  dissipate  the  pain 
and  help  the  action  of  the  local  means  used  to  deplete  the  organ 
during  the  first  period  of  treatment.  As  soon  as  walking  can  be 
allowed,  the  patient  should  be  provided  with  a  hypogastric  belt  to 
prevent  the  pain  and  increased  congestion  produced  by  the  weight  of 
the  abdominal  viscera  on  the  womb. 

Engoegement 

Engorgement  {infarctus)  is  a  permanent  tumefaction  constituted  by 
infiltration  of  organic,  amorphous,  liquid  or  semi-liquid  matter  between 
the  normal  anatomical  elements  of  the  organ.  It  should  be  admitted, 
as  well  as  congestion  and  fluxion. 

According  to  my  friend  and  colleague  M.  Charles  Robin,^  the  word 
engorgement  means  a  state  histologically  characterised  by  the  presence 
of  amorphous  matter,  half  solid  or  liquid,  which  has  exuded  between 
the  anatomical  elements,  and  which  keeps  them  apart.  This  matter 
when  liquid  or  half  liquid  holds  in  suspension  molecular  granulations, 
generally  fatty.  ...  In  the  half-solid  condition  in  the  hard  portions 
near  the  inflamed  parts  it  has  scattered  throughout  it  fatty  nitrogenous 
molecular  granulations,  with  or  without  those  granular  globules,  called 
globules  of  inflammation.  .  .  .  According  to  the  conditions  which  have 
caused  the  engorgement,  especially  in  amorphous  matter,  it  is  produced 
or  is  not  produced  from  fibro-plastic  elements  which,  added  to  those 
existing  normally  in  the  tissue,  make  the  engorgement  pass  into  the 
chronic  state  of  induration  or  hypertrophy. 

As  to  the  distinctive  signs  between  engorgement  and  the  other 
maladies  characterised  by  tumefaction,  it  is  sufficient  to  say  that, 
although  increased  size  is  common  to  engorgement,  fiuxion,  conges- 
tion, inflammation  and  hypertrophy,  there  is  in  engorgement  an 
absence  of  the  inflammatory  pain  so  characteristic  of  metritis,  of  the 
dark  red  or  violet  colour  of  congestion,  with  its  varicosities,  of  the 
uterine  or  visceral  sanguineous  raptus  of  fluxion,  and  of  the  consis- 
tency and  induration  of  hypertrophy. 

Lastly,  why  should  the  effect  of  treatment  not  be  invoked  as  a  final 
proof  of  the  existence  of  uterine  engorgement  ?  I  have  seen  cases  in 
which  I  have  not  used  any  of  the  means  necessary  in  the  treatment  of 
metritis,  fluxion,  congestion  or  hypertrophy,  cured  under  the  influence 
of  simple  resolvent  treatment,  determining  the  absorption  of  the  in- 
filtrated fluids  into  the  normal  tissue  of  the  organ.  I  remember  seeing 
a  case  of  tumefaction  of  the  uterus  which  had  lasted  for  several  years, 
and  which  had  occurred  after  a  difficult  labour.  The  information  given 
me  by  the  patient  was  insufficient  to  allow  of  my  determining  its  exact 
nature,  but  the  most  prominent  symptom  was  phlegmasia  alba  dolens. 
'  See  Diet.  Nysten,  article  Engorgement. 


ENGORGEMENT  473 

There  was  no  symptom  of  metritis,  hypertrophy,  fluxion,  nor  even  of 
congestion.  The  health  was  very  good,  but  walking  was  all  but  im- 
possible, and  the  increased  size  of  the  womb  was  the  only  apparent 
cause  of  the  trouble,  to  which  I  had  no  hesitation  in  giving  the  name 
of  engorgement.  I  could  not  persuade  the  patient  to  submit  to  treat- 
ment of  any  kind,  but  at  last  she  agreed  to  try  the  waters  of  Yichy  for 
a  month.  Soon  afterwards  she  wrote  me  word  that  the  uncomfortable 
sensation  she  experienced  in  the  pelvis  and  the  impossibility  of  walking 
disappeared  daUy  as  if  by  enchantment;  and  for  several  years  the  cure 
has  been  maintained. 

Diagnosis. — Engorgement  may  arise  spontaneously,  but  is  often  the 
consequence  of  congestion  or  inflammation.  It  may  exist  alone  or  co- 
exist with  congestion  (soft,  fungous,  bleeding  engorgement),  with 
hypertrophy  (hard  hypertrophic  engorgement),  and  even  with  fluxion 
and  inflammation ;  but  it  is  rare  in  the  latter  case  that  the  characters 
of  these  two  morbid  conditions  do  not  efface  those  of  engorgement 
itself.  Lastly,  it  may  depend  on  purely  local  conditions,  but  usually 
it  is  kept  up  by  a  diathetic  affection. 

Siuhjective  symptoms. — The  patient  experiences  a  disagreeable  sensa- 
tion of  fulness  and  weight  in  the  pelvis,  dragging  in  the  loins,  but 
less  than  in  congestion,  dragging  in  the  groins  propagated  to  the 
anterior  and  internal  surface  of  the  thighs,  heavy  pain  at  the  sacrum 
and  perinseum,  but  less  than  in  congestion  and  fluxion.  There  is  no 
sensation  of  heat  in  the  vagina  and  vulva,  but  often  pruritus.  Some- 
times a  uterine  mucous  or  muco-purulent  secretion  gives  rise  to  leu- 
corrhoea.  Usually  there  is  no  hesmorrhage  nor  want  of  regularity  in 
the  monthly  periods,  the  discharge  is  generally  rather  diminished  than 
increased  -,  engorgement  may,  however,  produce  menorrhagia  or  exces- 
sive menstruation.  Dysmenorrhcea  and  menorrhagia  arise  from  the 
engorgement  favouring  congestion  and  preventing  its  coming  to  a 
crisis  as  soon  as  usual.  The  symptoms  in  neighbouring  organs  are 
the  same  as  in  congestion.  But  the  bladder  and  rectum  usually  tole- 
rate engorgement  better  than  metritis,  fluxion  or  congestion;  consti- 
pation, however,  is  usual.  Lastly,  other  symptoms  will  be  added  to 
those  naturally  arising  from  the  preceding  when  the  patient's  local  and 
general  conditions  are  such  as  to  favour  the  development  of  engorge- 
ment. These  conditions  are :  repeated  deliveries  or  abortions,  exces- 
sive intercourse,  &c.,  as  well  as  a  rheumatic,  dartrous,  or  scrofulous 
diathesis. 

Objective  signs. — Palpation  associated  with  vaginal  touch  reveals 
an  increased  size  of  the  organ.  The  fundus  projects  slightly  beyond 
the  pubis,  unless  there  is  marked  prolapsus.  The  finger  when  in  the 
vagino-uterine  cul-de-sac  sometimes  feels  the  body  projecting  beyond 
the  neck.  The  vaginal  portion  of  the  neck,  as  if  ccdematous,  some- 
times acquires  such  large  proportions  that  the  largest  speculum  cannot 
embrace  it.  The  lips  are  often  turned  outwards  in  consequence  of 
tumefaction  opening  the  os  widely  in  women  recently  delivered.  One 
lip  is  often  much  larger  than  the  other,  but  the  engorgement  is 
general,  only  being  a  little  more  marked  on  one  lip  than  on  the  rest  of 


474  UTERINE    DISEASES    IN    DETAIL 

the  neck.  This  swelling  of  the  neck  is  not  accompanied  by  redness, 
but  occasionallj  the  neck  is  red  and  congested ;  more  frequently  it  is 
soft,  but  not  bleeding,  and  pale,  but  in  neither  case  is  there  any  sensa- 
tion of  heat  to  the  touch.  Often  the  uterus  is  displaced  or  deviated, 
as  it  is  after  any  increase  of  size  which  adds  to  its  weight,  but  we  must 
beware  of  thinking  that  displacements  are  the  necessary  results  of 
engorgement-  The  sound  shows  an  increase  in  the  length  as  well  as  a 
dilatation  of  the  uterine  cavity,  though  this  dilatation  is  less  than  in 
hypertrophy  proper.  Lastly,  there  may  exist  evident  signs  of  various 
complications,  e.g.  a  varicose  dilatation  of  the  veins  of  the  neighbour- 
ing organs,  of  the  broad  ligaments,  vagina,  bladder  and  rectum, 
showing  the  co-existence  of  congestion  with  engorgement,  or  vaginal 
leucorrhcea,  chronic  catarrh  of  the  bladder,  &c. 

Differential  diagnosis. — Engorgement  must  be  distinguished  from 
cedema,  jBuxion,  congestion,  inflammation,  hypertrophy,  inflammatory 
induration,  which  may  easily  be  confounded  with  it,  as  well  as  from 
scirrhous  induration,  fibroids  and  pregnancy,  which,  however,  are  more 
easily  distinguished.  In  all  these  morbid  conditions  there  is  total  or 
partial  increase  of  size  of  the  uterus.  The  elements  of  the  differential 
diagnosis  wnll  be  detailed  and  grouped  in  tables  in  the  description  of 
metritis. 

Treatment. — In  the  first  place  we  must  remember  that  engorgement 
is  curable  whilst  hypertrophy,  with  which  it  may  easily  be  confounded, 
is  not  so.  Further,  many  women  who  have  reached  the  climacteric 
do  not  ask  to  be  treated  for  engorgement,  because  pain  has  disap- 
peared or  can  be  alleviated  by  palliatives.  This  age  is  favorable  to 
the  tolerance  of  the  disease,  whilst  youth  is  favorable  to  cure,  being 
characterised  by  an  activity  of  circulation  which  facilitates  the  absorp- 
tion of  the  fluids  interposed  amongst  the  normal  uterine  elements ; 
moreover  the  very  functions  of  the  uterus,  menstruation  and  preg- 
nancy, may  be.  turned  to  account  as  means  of  cure,  the  retrograde 
evolution  which  takes  place  in  the  uterus  after  every  pregnancy  and 
after  every  menstrual  period  being  very  favorable  to  the  complete 
resolution  of  the  organ.     There  are  four  indications  to  be  fulfilled  : — 

1.  The  first  consists  in  turning  aside  the  fluxionary  movements,  dissi- 
pating the  congestion,  and  removing  all  causes  of  hypersemia  which 
facilitate  the  increase  or  prevent  the  resolution  of  the  engorgement. 
It  will  be  fulfilled  by  the  same  means  already  indicated  as  the  most 
suitable  for  subduing  fluxion  and  congestion.  Bloodletting  should  be 
very  cautiously  practised,  whilst  cutaneous  and  intestinal  revulsion, 
including  hydropathy,  should  be  resorted  to. 

2.  The  second  consists  in  rendering  the  exuded  fluids  capable  of 
being  absorbed  and  in  stimulating  the  normal  processes  of  the  organ 
and  economy,  by  which  means  we  may  hope  to  produce  this  absorp- 
tion. It  is  in  a  measure  special  to  engorgement  and  hypertrophy. 
In  order  to  bring  about  absorption  of  the  fluid  infiltrated  into  the 
normal  tissue  resolvent  medicaments  should  be  used,  or  rather  medi- 
cations capable  of  producing  this  result  by  the  modifications  which 
they  bring  about  in  the  functions,  and  by  the  special  activity  and 


ENGORGEMENT  475 

direction  which  they  give  to  general  and  local  nutrition.  These 
include  the  various  preparations  of  mercury  and  iodine,  especially 
iodide  of  potassium  given  internally.  The  same  preparations  as  well 
as  ointments  of  the  iodides  of  sulphur  and  mercury  may  also  be 
administered  by  the  rectum  or  vagina  or  in  frictions.  A  tampon 
saturated  in  a  glycerole  of  iodide  of  potassium  (60  grains  of  iodide  to 
the  ounce,  Scanzoni)  is  an  excellent  application,  to  which  we  may 
add  :  warm  sitz-baths  twice  daily,  vaginal  injections  and  wet  abdom- 
inal compresses,  the  water  used  for  the  baths,  injections  and  fomen- 
tations being  medicated  by  the  addition  of  a  solution  of  iodine  or 
bromine ;  painting  the  hypogastrium  with  the  tincture  of  iodine,  or 
the  application  of  an  ointment  of  the  iodide  or  bromide  of  potassium ; 
whilst  internally  we  may  prescribe  the  prolonged  use  of  mild  laxatives, 
alkalijie  mineral  waters  (Vichy,  Plombieres,  Vals,  Andabre)  and  iron, 
especially  the  iodide ;  from  the  alkaline  the  patient  may  pass  to 
chalybeate  waters  (Lamalou,  Bussang,  Oreza^  Sylvanes)  taking  the 
precaution  to  begin  by  mixing  one  third  of  the  iron  water  with  two 
thirds  of  the  alkaline  water;  lastly,  when  possible,  a  few  months 
should  be  spent  at  some  watering  place  where  the  patient  can  take 
baths,  drink  the  waters,  and  practise  hydropathy  simultaneously. 
The  best  in  such  circumstances  are  sulphur,  alkaline  and  iron  baths, 
especially  those  of  Vichy,  Vals,  Boulou,  Lamalou,  Sylvanes  and 
Andabre,  or  sea  bathing  and  hydropathy.  The  Arabic  treatment,  the 
cura  famis,  has  even  been  recommended ;  it  is  seldom,  however,  that 
the  latter  is  indicated. 

3.  The  third  indication  consists  in  treating  the  diathesis  which  has 
given  rise  to  the  development  of  engorgement  in  the  uterus.  Accord- 
ing to  whether  it  be  rheumatic,  scrofulous  or  herpetic  we  should 
recommend  sulphur  or  alkaline  baths,  hydropathy,  sea-bathing,  pre- 
parations of  iodine,  or  arsenic  in  small  doses  occasionally  interrupted, 
and  continued  long  enough  to  produce  a  deep  and  lasting  modification 
in  the  economy.  In  such  cases  one  of  the  most  energetic  and 
efficient  means  is  the  cauterisation  of  the  cervix,  especially  by  igni- 
puncture.  Some  of  the  ointments  enumerated,  especially  that  of  the 
red  iodide  of  mercury,  cause  suppuration.  A  blister  may  also  be 
applied  to  the  cervix,  but  the  least  painful  as  well  as  the  most  efficient 
application  is  that  of  the  actual  cautery  in  the  form  of  ignipuncture 
followed  by  baths,  purgatives,  alteratives,  hydropathy  and  resolvents 
of  every  kind.  By  taking  the  precaution  of  making  the  punctures  at 
some  distance  from  the  orifice  the  danger  of  contraction  is  avoided. 

4.  The  fourth  indication  is  palliative  treatment  consisting  in  alle- 
viating pain  by  baths,  sedatives,  antispasmodics ;  in  treating  constipa- 
tion by  mild  laxatives,  facilitating  digestion  by  bitters  and  tonics,  and 
in  supporting  the  abdominal  viscera  by  a  hypogastric  belt,  when,  as  is 
frequently  the  case,  they  cause  pain  by  their  pressure  upon  the  womb. 


476     ^  UTEEINE    DISEASES    IN    DETAIL 


Metritis 

Metritis  is  inflammation  of  the  uterus.  It  occupies  an  important 
place  in  uterine  pathology.  Inflammation  of  the  appendages,  ovaries 
and  Fallopian  tubes,  and  of  the  peri-uterine  tissues  (peri-uterine  in- 
flammation, peri-uterine  peritonitis)  are  also  common  diseases,  the 
reaction  of  which  on  the  organism  is  perhaps  still  greater  than  that  of 
metritis  strictly  so  called.  As  these  diseases  may  co-exist  or  succeed 
each  other  in  the  same  patient,  I  think  their  common  nature  is  more 
important  than  the  difference  of  seat,  and  therefore  I  shall  describe 
ovaritis  and  peri-uterine  inflammation  immediately  after  metritis. 

Pathological  anatomy. — The  lesions  produced  by  metritis  are :  in- 
creased size  of  the  organ,  infiltration  of  fluids  into  the  interstitial 
tissue,  and  the  consequent  softening  or  induration  of  the  latter, 
according  to  the  period  in  which  the  disease  is  seen ;  infiltration  under 
the  serous  fold  facilitating  detachment  of  the  peritoneum,  which  is 
red,  injected,  rough,  or  covered  with  false  membranes  ;  hypersemia  of 
the  mucous  membrane  and  organic  tissue,  the  capillaries  and  veins  in 
the  latter  being  gorged  with  blood.  The  mucous  membrane  is  red 
and  dotted,  with  but  few  traces  of  the  arbor  vitse.  In  cases  where 
the  mucous  membrane  alone  is  diseased  there  is  in  addition  consider- 
able tumefaction  of  the  membrane,  the  appearance  of  papillse,  the 
projection  of  follicular  orifices  surrounded  by  a  vascular  network 
gorged  with  blood,  softening,  epithelial  denudation  and  even  ulcera- 
tion, not  to  speak  of  granulations  and  fungosities  which  may  also  be 
developed  in  the  chronic  state.  Sometimes  these  alterations  are 
arrested  suddenly  at  the  os  internum,  whilst  the  mucous  membrane  of 
the  cervix  is  healthy  or  almost  so.  However,  endometritis  hardly 
ever  exists  without  being  accompanied  by  some  parenchymatous 
metritis.  Lastly,  lesions  depending  on  suppuration,  phlebitis,  &c.,  as 
the  results  and  complications  of  inflammation  in  all  other  organs, 
may  be  observed  in  the  uterus  as  a  consequence  of  metritis.  Pus  is 
sometimes  found  in  the  uterine  cavity  or  in  the  parenchyma  \  but 
suppuration  is  very  rare  in  the  non-puerperal  condition.  We  must 
therefore  ascertain  whether  some  debris  of  membrane  or  placenta  has 
not  remained  in  the  uterine  cavity,  or  if  the  interstitial  pus  has  not 
formed  round  a  clot  in  a  venous  sinus  or  if  the  suppuration  does  not 
arise  from  a  lymphatic  vessel. 

These  lesions  characterise  acute  and  chronic  metritis  alike.  Only 
in  the  former  they  disappear  more  quickly  whether  the  disease  termi- 
nates by  resolution  or  suppuration.  Therefore  they  are  more  fre- 
quently observed  in  a  uterus  affected  with  chronic  inflammation.  The 
softening  and  induration  which  characterise  the  first  and  second  period 
of  inflammation  in  all  the  tissues  also  characterise  both  periods  in 
chronic  metritis. 

Scanzoni^  has  rightly  distinguished  '^  a  period  of  softening  or  iii- 
filtration,  in  which  a  more  or  less  extensive  hypersemia  is  observed,  a 
'  Die  Chronisclie  Metritis.     Wien,  1863.,  S.  35  et  seq. 


METRITIS 


477 


sero-sanguinolent  infiltration  of  the  uterine  tissue  which  after  this 
imbibition  becomes  soft,  relaxed  and  thickened,  from  a  second  period 

A 


Fig.  313.— Chronic  cystic  polypous  endometritis  (after  Virchow).  The  os  ex- 
ternum is  dilated  in  the  form  of  a  funnel,  and  the  two  lips  are  the  seat  of 
a  considerable  swelling.  A  number  of  Naboth's  eggs,  isolated  or  grouped 
together,  rise  above  the  swollen  and  hypersemiated  tissue  (acne).  To  the 
right  of  the  section  we  see  that  these  mucous  cysts  do  not  belong  only  to 
the  surface,  but  extend  to  a  considerable  depth.  Higher  up  in  the  cervical 
canal  the  folds  are  strongly  marked,  and  give  rise  to  a  series  of  vesicular 
or  fleshy  polypi,  especially  to  the  left,  where  a  large  pediculated  pyriform 
one  is  found,  which  reaches  almost  to  the  os  internum.  Some  small 
mucous  cysts  are  also  to  be  seen  in  the  os  internum.  Then  comes  the 
slightly  dilated  cavity  of  the  uterine  body,  which  was  filled  with  fluid,  and 
the  mucous  membrane  of  which  is  smooth  (hydrometra  levis).  A  little 
above  the  os  internum  and  to  the  left  on  the  wall  a  large  fibroma  mollus- 
cum  (m)  is  seen  containing  mucous  cysts  which  before  incision  almost 
entirely  stopped  up  the  internal  os.  Higher  up  at  m'  is  a  smaller  one, 
near  the  orifice  of  one  of  the  Fallopian  tubes.  The  uterine  wall  as  a  whole 
is  thinner  ;  but  in /and/'  it  contains  two  interstitial  myomata  (fibroids) 
of  small  size.  A  third,  rather  larger,  causes  the  projection  indicated  by 
the  shining  spot  on  the  posterior  portion  which  is  not  incised. 

of  tliichening  or  induration  in  which  general  or  partial  anaemia  of  the 
organ,  desiccation,  firmness  and  hardness  of  the  tissue  are  the  prin- 
cipal lesions. 

In  the  first  period  (of  softening  and  hypersemia)  tliere  may  be  excess 
and  disturbance  of  the  secretions  of  the  mucous  foUicules,  neoplasms 
of  all  kinds  may  be  formed,  especially  adenomata,  follicular   tumours 


478  UTEEINE    DISEASES    IN    DETAIL 

and  fibro-myomaia,  or  a  general  hypertrophy  of  the  organ  may  be  pro- 
duced. The  woodcut  taken  from  Yirchow  presents  a  striking  and 
common  example.  These  neoplasms  may  be  developed  in  consequence 
of  the  hypertrophic  tendency  of  the  tissue,  owing  to  local  disease  of 
the  excretory  canal  of  the  glands,  of  the  fibro-plastic  elements  of  the 
mucous  membrane,  of  the  smooth  fibres  of  the  tissue,  &c.  Its  for- 
mation, however,  is  favoured  by  inflammation.  The  intervention  of 
inflammation  may  be  recognised  in  the  fact  that,  in  place  of  being 
formed  on  one  point  or  on  one  tissue  only,  the  neoplasms  are  developed 
at  every  point  and  on  all  the  tissues  at  once. 

In  the  second  stage  (induration),  in  place  of  presenting  an  infiltra- 
tion of  amorphous  matter  as  in  engorgement,  the  tissue  of  the  uterus 
is  hardened.  It  is  the  index  of  resolution,  but  of  incomplete  resolu- 
tion. The  hypersemia  aTid  softening  disappear,  the  plastic  inflamma- 
tory activity  is  extinguished ;  but  the  absorption  of  the  neoplastic 
elements  is  not  complete;  it  does  not  extend  to  the  connective  tissue 
as  to  the  other  elements.  Therefore  induration  persists  as  the  trace 
of  proliferation  of  this  fibrillar  tissue ;  there  remains  in  the  uterus  a 
network  of  fibrous  tissue  analogous  to  cicatricial  tissue. 

According  to  Scanzoni,  independently  of  this  induration  of  tissue 
producing  partial  or  general  ansemia  of  the  organ,  the  most  important 
anatomical  modification  in  chronic  metritis  is  the  congestion  of  the 
engorged  and  dilated  vessels.  This  congestion  is  due  to  the  disturb- 
ances observed  in  the  circulation  of  the  neighbouring  organs,  and  to 
the  want  of  tone  in  the  walls  of  the  vessels  which  do  not  present 
sufficient  resistance  to  regulate  the  circulation.  It  is. evident  that  this 
congestion  is  more  considerable  during  the  period  of  softening,  but  to 
some  extent  it  persists  during  the  period  of  induration,  especially  at 
the  commencement.  T/iis  congestion  is  especially  venous,  and  is  the 
most  difficult  to  dissipate ;  therefore  Scanzoni,  generalising  too  much, 
regarded  chronic  metritis  as  incurable. 

It  is  rare  for  the  anatomical  alterations  to  be  disseminated  uniformly 
through  the  various  portions  of  the  uterus,  and  for  them  to  reach  all, 
especially  when  the  metritis  is  chronic.  In  the  latter  case  we  not  only 
ascertain  that  these  lesions  may  be  limited  to  the  body  or  to  the  neck 
of  the  organ,  but  usually  also,  according  to  the  ingenious  comparison 
of  Gallard  [Legons  cliniques  snr  les  maladies  des  femmes,  pp.  143, 
153,  172,  &c.,  Paris,  1873),  in  the  uterus  as  in  the  heart,  inflamma- 
tion may  reach  the  external  or  serous  envelope,  the  internal  or  mucous 
covering,  and  the  intermediate  or  parenchymatous  tissue.  It  is  more 
uncommon  to  see  inflammatory  lesions  aff'ecting  exclusively  the  mus- 
cular tissue  than  the  mucous  or  serous  tissue,  except  in  the  acute 
stage ;  they  may  even  sometimes  exclusively  affect  the  cellular  tissue 
interposed  between  the  organ  and  its  serous  covering  (parametritis). 
The  principal  and  characteristic  alterations,  however,  may  be  limited 
sometimes  to  the  mucous  membrane  (endometritis  or  mucous  metritis), 
sometimes  to  the  muscular  tissue,  whilst  reacting  on  the  peritoneum  or 
being  somewhat  propagated  to  the  internal  membrane  (idiometritis  or 
parenchymatous  metritis). 


METRITIS  479 

The  majority  of  pathologists  have  not  pushed  their  researches  further 
as  to  the  diversity  of  the  alterations  which  may  be  produced,  and  yet 
it  seems  to  me  that  in  place  of  being  satisfied  with  distinguishing 
mucous  from  parenchymatous  metritis,  it  is  necessary  further  to  deter- 
mine the  element  principally  affected  or  exclusively  altered  in  each  of 
these  tissues  according  to  the  seat  of  the  evil. 

This  last  division,  founded  on  the  histological  localisation  of  the 
morbid  product,^  is  perhaps  the  most  important  to  know,  as  regards 
not  only  the  histological  element  affected  by  inflammation,  but  also 
the  pathological  evolution  which  this  element  undergoes,  and  which 
more  or  less  profoundly  modifies  its  structure  and  functions,  sometimes 
in  one  direction,  sometimes  in  another.  The  agreement  between  each 
histological  alteration  and  each  symptomatic  table,  subjective  and  ob- 
jective, is  the  best  source  of  pathological  determination  and  thera- 
peutic indication.  Therefore  it  may  be  said  that  the  diversity  of 
histological  alteration  ansioers  to  the  diversity  of  nature  of  the 
inetritis. 

If  we  have  to  do  with  a  case  of  endometritis  we  sometimes  find  the 
alteration  very  superficial,  limited  to  the  epithelium,  which  may  be 
now  removed  or  destroyed  by  an  erosion,  now  stimulated  to  prolifera- 
tion, which  gives  to  the  membrane  a  granulated  aspect  (grey  granula- 
tions of  small  superficial  dimensions)  ;  at  other  times  the  alteration 
will  invade  the  glands,  increasing  the  secretion  (leucorrhoea),  or  exciting 
a  proliferation  capable  of  producing  various  kinds  of  tumours  (granula- 
tions vi^ith  a  hole,  or  a  trace  of  one,  at  the  projecting  portion,  a  cyst, 
Naboth's  eggs,  adenomata,  follicular  polypi  sessile  or  pediculated). 
It  gains  in  extent,  reaching  the  vascular  system,  sometimes  simply  con- 
gesting it  (venous  congestion  of  troublesome  persistency),  sometimes 
disposing  the  superficial  congested  network  to  lacerations  and  haemor- 
rhage (hsemorrhagiparous  endometritis),  or  it  determines  by  a  conges- 
tion, which  is  the  result  of  persistent  and  localised  erection,  small 
fungous  tumours  or  bleeding  granulations  having  a  more  or  less  distant 
analogy  to  a  hsemorrhoidal  tumour  or  a  tumour  partly  erectile.  At 
other  times  the  alteration  while  producing  superficial  lesions  gains  in 
depth,  affecting  specially  the  dermis  of  the  mucous  membrane  when, 
owing  to  its  proliferative  or  destructive  tendency,  it  produces  true 
papillary  granulations,  more  or  less  voluminous  and  confluent,  some- 
times hard,  sometimes  fungous  (if  they  are  associated  with  excessive 
vascularity),  or  on  the  contrary  with  more  or  less  large  and  deep  ulcers 
of  variable  form,  according  to  the  diathesis  on  which  they  depend.  If 
the  alteration  affects  the  cellular  tissue,  the  elements  of  the  connective 
tissue,  and  the  fibro-plastic  or  embryonic  elements,  the  fusiform  bodies, 
&c.,  the  proliferation  of  these  elements  may  give  rise  to  superficial 
granular  vegetating  hypertrophy,  simple,  fungous  or  polypiform,  or  to 
deep  hypertrophy  affecting  the  whole  thickness  of  the  mucous  mem- 

*  Memoire  sur  la  diversite  des  alterations  histologiques  dans  I'injlammation 
de  I'uterus,  presented  to  the  Acadeinie  des  Sciences,  May  20,  1877,  and  read 
before  the  French  Association  foi'  the  Advancement  of  Science  at  the  Mont- 
pellier  meeting,  August,  1879. 


480  UTERINE    DISEASES   IN    DETAIL 

brane  and  the  whole  extent  of  one  region ;  for  instance,  one  segment 
of  the  body,  one  of  the  lips  of  the  cervix,  a  general  hypertrophy, 
leading  in  the  first  period  to  softening,  and  later  on  to  induration.  As 
for  suppurative  phlebitis,  lymphangitis,  peri-uterine  or  retro-uterine 
adenitis,  they  are  met  with  as  serious  complications  of  certain  kinds  of 
metritis,  especially  of  puerperal  metritis  or  (adenitis  especially)  as  an 
indication  of  ulceration  persistent  for  a  long  time  over  a  considerable 
extent  of  the  mucous  membrane,  necessitating  special  applications  to 
this  mucous  membrane,  and  often  keeping  up  in  patients  pain  which 
till  now  has  not  been  accounted  for,  but  the  interpretation  of  which 
appears  to  me  now  undoubted. 

If  we  have  to  do  with  parenchymatous  metritis  without  superficial 
anatomical  lesions  which  are  necessarily  absent,  we  find  according  to 
the  case  pathological  alterations  analogous  to  those  just  described  in 
the  thickness  of  the  mucous  membrane,  affecting  the  like  histological 
elements,  the  vascular  system,  the  fibro-plastic  elements,  the  laminar 
tissue,  &c.,  and  special  alterations  affecting  the  constitutive  element 
par  excellence  of  the  uterine  muscular  tissue,  I  mean  the  smooth  fibre. 
The  principal  anatomical  alterations  of  the  smooth  muscular  fibre  are 
either  a  simple  hypertrophy  without  localised  and  limited  proliferation 
(hypertrophic  parenchymatous  metritis),  or  a  special  localised  prolifera- 
tion, producing  globular  tumours,  simple  or  multiple  (fibroids,  fibro- 
mata, myomata,  leiomyoraata),  among  which  the  myomata  (prolifera- 
tions of  the  smooth  muscular  fibres)  should  be  distinguished  from 
fibromata  or  fibroids  or  fibro-plastic  tumours  (proliferation  of  connec- 
tive tissue  and  embryonic  fibro-plastic  elements),  both  possibly  being 
interstitial,  subserous,  submucous  (sessile  or  pediculated).  Others 
consist  in  a  softening  with  serous  infiltration  or  fatty  degeneration 
(softening  parenchymatous  metritis).  Others  again  consist  in  a  more 
or  less  painful  contraction  of  these  fibres  v\'ith  consecutive  retraction 
or  induration  (indurated  parenchymatous  metritis,  retractile,  often 
painful). — As  for  the  alterations  of  the  cellular  and  especially  of  the 
vascular  system,  they  resemble  those  of  the  same  elements  in  the 
mucous  membrane  :  there  may  be,  though  rarely,  suppuration  and 
even  an  abscess ;  the  same  venous  congestion  is  produced,  associated 
with  a  venous  congestion  coexisting  in  the  mucous  membrane,  sharing 
in  the  same  characteristics  of  incurability,  redoubled  when  the  venous 
congestion  extends  to  the  two  principal  histological  layers  of  the  uterus. 
In  the  other  organic  alterations  there  is  nothing  which,  from  the  point 
of  view  of  curability,  is  beyond  the  power  of  medical  art. 

Divisions. — The  divisions  that  have  been  established  between  the 
various  kinds  of  metritis  depend  on  the  meaning  attached  to  the  term 
metritis  in  the  domain  of  uterine  pathology. 

1.  With  regard  to  its  extent,  it  may  be  general  or  limited  according 
to  whether  it  affects  the  whole  uterus  or  only  one  of  its  parts. 

2.  As  to  its  localisation  metritis  may  be  total  or  partial.  Some 
physicians  designate  metritis  of  the  cervix  by  the  term  external 
metritis.     It  is  certain  that  partial  inflammation  may  be  limited  to  the 


METRITIS  481 

neck  or  to  the  body,  may  affect  either  the  parenchyma  or  the  mucous 
membrane. 

3.  With  regard  to  its,  progress,  metritis  may  be  in  both  cases  oxute, 
subaaUe,  or  chronic.  That  occurring  after  delivery  is  generally  acute. 
Chronic  metritis  is  the  form  most  commonly  met  with  in  the  non- 
puerperal state,  the  chronic  form  being  assumed  even  from  the  begin- 
ning. The  acute  or  subacute  form,  however,  is  sometimes  met  with, 
especially  when  the  metritis  is  due  to  traumatism :  excessive  inter- 
course, dysmenorrhcea,  the  fatigue  attending  a  wedding  tour,  the 
sudden  suppression  of  menstruation,  &c.  Mikschik  has  published  an 
interesting  work  on  acute  metritis  in  the  non-puerperal  state. ^  It  is 
based  on  18  cases,  13  of  which  were  women  who  had  never 
conceived  :  all  fell  suddenly  ill  during  menstruation ;  the  majority  had 
taken  cold,  and  in  6  there  had  been  a  traumatism  at  that  time. 
Except  where  complications  exist  in  connection  with  the  appendages 
cure  is  always  obtained.  This  form  of  metritis  according  to  Mikschik 
is  rare,  only  occurring  twice  in  every  100  cases.  Tilt^  is  of  the  same 
opinion,  and  so  am  I.  Slawjansky's  ^  opinion  that  cholera  can  develop 
hgemorrhagiparous  endometritis  has  never  been  confirmed. 

4.  With  regard  to  the  diversity  of  causes,  metritis  has  been  divided 
into  piLcrperal  and  non-puerperal.  Chomel  goes  further,  distinguish- 
ing puerperal  metritis,  which  is  developed  immediately  after  delivery, 
from  post-puerperal  metritis  developed  some  days  later.  I  cannot  see 
any  other  difference  between  puerperal  and  non-puerperal  metritis 
than  that  resulting  from  the  extreme  tendency  of  the  former  to  suppu- 
ration and  from  the  frequency  of  complications,  such  as  lymphangitis, 
phlebitis,  peritonitis,  &c.,  which  increase  the  gravity  of  the  prognosis. 

I  shall  not  here  refer  to  the  question  of  puerperal  fever,  which  has 
not  been  settled.  In  any  case  it  must  be  admitted  that  if  puerperal 
metritis  has  been  included  in  the  description  of  puerperal  fever  and 
has  altered  its  features,  it  has  also  been  proved  that  newly  delivered 
women  may  succumb  to  serious  fever,  which  often  coincides  with 
pathological  alterations  in  the  uterus  as  in  other  organs,  indeed,  more 
than  in  other  organs,  but  which  may  also  leave  no  trace  in  the  womb, 
as  has  been  proved  by  autopsies,*  and  which  consequently  is  not  merely 

^  Acute  metritis  in  non-pregnant  women,  Zeitschr.  der  Gesellsch.  der  Aerzte 
zu  Wien,  1855,  Bd.  xi,  S.  500. 

^   Transact,  of  the  Obstetric.  Sac,  vol.  xiii,  p.  197. 

^  Archivf.  Gynaehologie,  Bd.  iv,  S.  212. 

''  Many  physicians  believe  that  puerperal  fever  is  an  essential  disease  charac- 
terised by  an  alteration  in  the  blood.  To  sum  up  the  facts  on  which  their 
opinion  is  based,  it  is  sufficient  to  refer  to  the  case  of  the  midwife  who  suc- 
cumbed to  puerperal  fever,  or  at  least  to  a  disease  which  presented  all  the 
characters  of  it,  although  she  was  a  virgin  and  was  not  menstruating  at  the 
time.  I  may  also  remark  that  Lorain  in  his  thesis  {De  V etat  puerperal  cliez  le 
fcetus  et  le  nouveau-ne.  Paris,  1855)  has  shown  the  solidarity  existing  in  this 
respect  between  the  mother  and  child.  Besides,  it  is  doubtless  the  same  with 
puerperal  fever  as  with  contagious  erysipelas  and  purulent  infection.  1.  It 
may  be  developed  in  a  woman  (recently  delivered)  from  uterine  phlebitis  or 
angioleucitis,  from  the  absorption  of  pus,  from  suppurative  metro-peritonitis, 
from  ovaritis,  from  an  abscess  of  the  broad  ligaments,  from  a  consecutive 
purulent  infection.     2.  It  may  afterwards  be  propagated  by  the  miasma  to 

31 


482  UTERINE    DISEASES    IN   DETAIL 

a  fever  symptomatic  of  metritis  or  uterine  phlebitis.  However,  it  is 
not  with  the  existence  of  puerperal  fever  but  of  puerperal  metritis 
that  we  have  to  do.  As  the  latter  cannot  be  disputed,  the  only 
question  to  be  decided  is,  whether  puerperal  metritis  and  non-puer- 
peral uterine  inflammation  are  not  the  same  disease  with  complica- 
tions. 

5.  Non-puerperal  metritis  may  be  divided  into  traumatic  metritis 
and  diathetic  or  specific  metritis,  of  which  there  are  various  kinds  : 
rheumatoid,  catarrhal,  diphtheritic,  &c. 

6.  "With  regard  to  the  termination  metritis  has  been  divided  into 
leucorrliceic,  suppurative,  ulcerous,  gangrenous,  granular,  fungous, 
softening,  congestive,  hypertrophic,  indurated,  &c. 

7.  Prom  the  point  of  view  of  histological  diversity  the  term  endo- 
metritis is  used  to  denote  inflammation  affecting  the  mucous  mem- 
brane ;  some  writers  have  also  called  it  internal  or  catarrhal  metritis, 
wrongly  confounding  it  with  uterine  catarrh.  Idiometritis  (Her- 
vieux)  or  parenchymatous  metritis  is  used  to  describe  inflammation 
of  the  muscular  tissue  of  the  organ ;  parametritis  (Matthews  Dun- 
can) to  denote  inflammation  of  the  cellular  tissue  surrounding  the 
uterus  j  and  exometritis  inflammation  of  the  peritoneal  covering  which 
is  easily  propagated  to  the  broad  ligaments,  whilst  it  frequently 
spares  the  uterine  tissue. 

8.  "With  regard  to  the  localisation  of  the  pathological  process  on 
one  of  the  constitutive  elements  of  the  principal  tissues  of  the  organ, 
distinctions  have  been  established  between  the  various  histological 
varieties  which  seem  to  me  the  most  important  of  all ;  the  principal 
are :  glandular  qx  follicular,  granular ,  fungous,  vasc^dar,  hemorrhagic, 
congestive,  venous,  proliferant,  hypertrophic,  softening,  indurated, 
&c.  The  importance  of  this  classification,  based  upon  pathological 
anatomy,  is  recognised  in  the  diagnosis,  prognosis  and  treatment, 
and  really  dominates  the  pathology  of  metritis. 

9.  With  regard  to  complications,  metritis  may  be  simple  or  complex. 
The  complications  are  inflammation  of  the  ovary,  of  the  Pallopian  tube, 
peri-uterine  inflammation,  peritonitis,  abscesses  either  peri-uterine, 
pelvic  or  iliac  ',  lastly,  lymphangitis,  phlebitis,  phlegmasia  alba  dolens 
and  purulent  infection,  which  are  the  most  serious  complications  of 
metritis,  at  least  of  puerperal  metritis. 

Causes. — Metritis,  like  all  other  uterine  diseases,  occurs  most  fre- 
quently during  the  period  of  greatest  sexual  activity.  According  to 
Nonat  the  greatest  number  of  uterine  inflammations  is  from  fifteen  to 

■wMch  it  lias  given  birth,  and  determine  septicaemia  in  pnei-peral  women  or  in 
those  who  have  been  operated  on  in  a  hospital.  3.  It  may  even,  in  women  of 
the  latter  class,  be  localised  on  the  uten;s,  this  organ  being  predisposed  by 
recent  delivery,  or  being  already  a  centre  of  suppuration.  4.  It  is  all  the 
more  likely  to  end  fatally  in  that  it  attacks  patients  doubly  with  septicismia  : 
by  direct  purulent  infection  from  the  uterus,  and  by  indirect  or  epidemic  in- 
fection. To  sum  up,  I  agree  with  Hervieux  {Traite  clinique  et  pratique  cles 
tnaladies  puerperales  suites  des  couches,  p.  82.  Paris,  1870)  that  a  midwifery 
hospital,  permanently  occupied,  is  a  productive  cause  of  miasma,  and  that  the 
propagation  of  this  miasma  by  infection  or  contagion  produces  puerperal  j)oison 
and  puerperal  fever. 


METRITIS  483 

forty-five  years,  and  the  age  at  which  women  are  most  exposed  to 
metritis  is  from  twenty  to  thirty  years. 

Debilitated  constitutions  and  lymphatic  temperaments  seem  more 
disposed  than  others  to  metritis.  The  uterus  seems  specially  disposed 
to  become  inflamed  in  certain  women,  from  a  kind  of  weakness  or 
natural  susceptibility,  according  to  Henry  Bennet,^  but  I  think  there 
is  a  natural  susceptibility  of  the  organ  which,  according  to  Nonat, 
sometimes  runs  in  families,  and  which  predisposes  to  other  uterine 
diseases  as  well  as  to  metritis. 

It  is  difficult  to  decide  whether  the  kind  of  life  led  by  the  poor  or 
rich,  the  action  of  certain  kinds  of  food  (coffee),  certain  garments 
(stays),  climate  (damp,  sudden  or  prolonged  cold),  certain  diseases 
{e.(j.  diathetic  conditions,  cardiac,  gastric,  pulmonary  or  hepatic  dis- 
eases), certain  medicaments  (vaginal  injections  or  emmenagogues^) 
predispose  to  metritis. 

The  influence  of  determining  causes  is  more  evident.  All  that  con- 
gests or  irritates  the  organ  may  develop  inflammation  of  the  uterus. 
Menstrual  disorders,  and  especially  the  sudden  suppression  of  the 
catamenia,  abortion,  natural  and  artificial  delivery,  including  subse- 
quent accidents  such  as  retention  of  the  placenta,  laceration  of  the 
cervix,  disappearance  of  the  lochia  or  milk,  inflammation  of  the 
placental  wound,  arrested  histological  involution  of  the  uterus,  &c.,  are 
the  most  frequent  causes.  Also  excessive  intercourse,  especially  during 
wedding  tours,  rising  too  soon  after  a  confinement  or  resuming  marital 
intercourse  too  early,  disproportion  in  the  size  of  the  penis,  masturba- 
tion, the  prolonged  presence  of  foreign  bodies  in  the  vagina,  such  as 
pessaries  or  sponges,  the  uterine  douche,  the  introduction  of  dilating 
bodies  to  induce  abortion,  drawing  the  uterus  down  to  facihtate  the 
extirpation  of  a  polypus,  incision  of  the  cervix  or  forced  dilatation,  the 
use  of  the  sound,  the  ill-timed  introduction  of  an  intra-uterine  stem, 
frequent  cauterisation  of  the  cervix,  especially  when  done  in  the  con- 
sulting room  and  without  the  use  of  the  precautions  I  have  indicated^ 
may  cause  metritis. 

Other  traumatisms,  such  as  a  fall  on  the  pelvis  or  abdomen,  a  blow, 
shock  or  wound  received  on  the  hypogastrium  or  in  the  vagina,  may 
also  be  determining  causes  of  metritis ;  for  in  spite  of  its  internal 
position  in  the  pelvic  cavity,  and  the  thickness  of  the  hard  and  soft 
parts  protecting  it,  the  uterus  is  exposed  not  only  to  indirect  but 
occasionally  to  direct  traumatisms.^ 

^  Op.  cit.,  p.  34. 

-  Kiinding  {Schweiz.  Zeitsch.,  1839,  Bd.  i,  2*^  Heft)  has  seen  a  woman  who, 
after  the  use  of  savin  and  other  abortives,  presented  symptoms  of  chronic 
metritis  and  peritonitis.  At  death,  which  occurred  in  the  forty-first  week  o£ 
pregnancy  from  exhaustion,  the  uterus  was  found  adherent  to  the  neighbouring 
parts  and  had  not  increased  in  thickness  as  in  pregnancy.  As  for  the  fcetus  it 
died  in  the  seventh  month. 

^  Tacheron,  Annales  d'Hygiene,  April,  1834  ;  Revue  viedicale,  1835,  t.  i,  p. 
117  ;  Gazette  mklicule,  1841,  p.  219  ;  Ibid.,  1845,  p.  716  ;  Planchon,  Traite 
complet  de  V operation  ccsarienne,  p.  77  ;  Deneux,  Essai  stir  les  ruptures  de  la 
matrice,  p.  35  ;  Czazewski,  Journal  de  Malgaigne,  Dec,  1846  ;  Revue  medicale, 
1841,  t.  iii,  p.  389  ;  Ibid.,  1844,  t.  iii,  p.  83  ;  Journal  de  medecine,  1786,  t.  Ixvi, 


484  UTERINE    DISEASES    IN   DETAIL 

Poma^  asserts  that  he  has  seen  a  case  of  metritis  caused  by  the  in- 
troduction of  a  leech  into  the  uterus ;  the  disease  did  not  decKne  for 
a  fortnight  till  after  the  expulsion  of  a  large  clot  containing  a  leech  in 
good  condition. 

Inflammation  already  existing  in  neighbouring  organs  may  be  pro- 
pagated to  the  uteruSj  such  as  ovaritis,  inflammation  of  the  Eallopian 
tubes,  vaginitis  and  peri-uterine  phlegmons,  which  act  as  tumours 
hindering  the  circulation,  as  centres  of  fluxion  or  congestion,  and 
especially  as  seats  for  the  propagation  of  inflammation  by  continuity. 
As  for  the  rectum  and  bladder,  the  inflammation  is  propagated  rather 
from  the  uterus  towards  these  organs  than  from  these  organs  towards 
the  uterus. 

Course. — It  may  be  either  acute  or  chronic,  sometimes  even  sub- 
acute. 

The  acute  stage  may  be  very  serious,  progressing  rapidly,  terminat- 
ing by  suppuration  or  gangrene,  or  be  complicated  by  phlebitis, 
lymphangitis  or  by  purulent  or  putrid  absorption.  These  terminations 
and  complications  are  peculiar  to  the  puerperal  state.  Other  compli- 
cations occur  frequently  in  non-puerperal  acute  metritis.  Inflammation 
of  the  peritoneum,  of  the  annexes,  and  peri-uterine  inflammation  must 
be  placed  in  the  first  rank.  Metritis,  indeed,  in  place  of  being  simple 
is  frequently  metro-peritonitis,  the  most  superficial  layer  of  the  uterine 
tissue  and  the  serous  fold  covering  it  being  either  simultaneously  in- 
flamed from  the  beginning  or  the  inflammation  may  have  extended 
from  the  muscular  to  the  serous  tissue  owing  to  want  of  care  and 
prudence  on  the  part  of  the  patient.  It  is  the  same  with  inflammation 
of  the  annexes,  especially  with  ovaritis,  which  is  frequently  met  with, 
and  sometimes  in  a  more  marked  degree  than  the  concomitant 
metritis.  Peri-uterine  inflammation  is  a  complication  which  is  not 
very  rare,  and  which  aggravates  metritis,  necessitating  more  energetic 
treatment. 

When  inflammation  of  the  mucous  membrane  has  reached  such  a 
degree  that  the  membrane  is  ulcerated  at  several  points  and  stripped 
of  its  epithelium,  these  bleeding  surfaces  may,  though  rarely,  contract 
adhesions  at  points  of  contact.^ 

At  the  OS  internum  the  contact  is  so  close,  that  the  alteration  of  the 
mucous  membrane  may  produce  definite  occlusion  of  this  orifice.  This 
accident  is  usually  prevented  by  the  continual  interposition  of  mucus 
between  the  surfaces  of  the  mucous  membrane  of  the  isthmus.     The 

p.  354 ;  Emmet,  Principles  and  Practice  of  Gynecology,  1879 ;  Gazette  medi- 
cale,  1836,  p.  536  ;  Ibid.,  1834,  p.  87  ;  Ibid.,  1835,  p.  265  ;  Ibid.,  1839,  p.  185  ; 
Ohservateur  des  Sciences  medicales  de  Marseille,  1822,  t.  iv,  p.  251 ;  Deutsche 
Klinih,  1862,  No.  11 ;  Larcher,  Archiv.  gen.  de  medecine,  1869. 

1  Gazz.  di  Milano,  1846,  No.  38. 

2  I  bave  seen  three  cases  of  the  kind  in  autopsies  on  aged  women,  another  in 
a  young  woman,  and  one  in  a  patient  afEected  with  syphilis.  The  occlusion  of 
the  orifice  from  such  adhesions  is  not  rare  in  old  women.  I  have  an  example 
of  the  kind  in  one  of  my  patients  at  present,  a  young  woman.  Ulcerations  of 
the  OS  externum  from  the  lower  portion  of  the  cervical  canal  have  contracted 
adhesions,  and  caused  obliteration  after  three  or  four  years  of  continued  in- 
flammation. 


METRITIS  485 

length,  liowevePj  of  the  isthmus  may  dispose  it  to  be  obliterated  more 
easily.  This  is  what  sometimes  happens  when  internal  metritis  has 
lasted  a  long  time,  and  when  the  patient  has  reached  an  age  when  the 
natural  contraction  of  this  orifice  and  even  its  obliteration  are  not 
rare.  There  results,  as  may  readily  be  supposed,  a  distension  of  the 
cavity  of  the  body,  owing  to  the  mucus  or  muco-pus  abnormally 
retained.  The  body  then  takes  a  more  and  more  globular  form,  and 
its  wails  may  be  thinned.  The  external  os  may  also  become  oblite- 
rated, though  more  rarely.  Its  two  lips  are  then  united  by  a  mem- 
branous adhesion  or  by  a  fibro-cellular  band.  The  cavity  of  the  neck 
is  distended,  the  mucus  secreted  is  accumulated,  the  internal  os  is 
enlarged,  and  the  cavities  of  the  body  and  neck  communicate  freely 
with  each  other.  One  of  the  most  interesting  cases  of  this  kind  is  that 
published  by  Yoisin  of  Limoges.^ 

Inflammation  of  the  peritoneum  has  a  greater  tendency  even  than 
that  of  the  uterine  mucous  membrane  to  produce  consecutive  adhe- 
sions. Therefore  metritis  when  complicated  with  peritonitis  cannot 
be  subdued  too  energetically ;  for  the  (almost  fatal)  consequences  of 
the  latter  are  adhesions  between  the  peritoneal  fold  covering  the 
uterus  and  that  covering  its  annexes  or  the  neighbouring  organs. 
Hence,  if  the  womb  be  deviated  or  flexed,  fixity  of  this  organ  in  an 
abnormal  situation  may  indefinitely  keep  up  the  diseases  which  are 
the  consequence  of  this  situation,  such  as  engorgement,  congestion, 
dysmenorrhoea,  &c.  Hence  also  adhesions  of  the  womb  with  the 
rectum,  and  the  double  hindrance  to  the  functions  of  the  uterus  and 
this  intestine,  as  well  as  loss  of  mobility  of  the  Fallopian  tube  and  its 
fimbriated  extremity,  the  union  of  the  uterus  sometimes  with  this 
organ,  sometimes  with  the  ovary,  pains  produced  by  the  disturbance 
of  their  functions,  especially  at  the  menstrual  periods,  the  impos- 
sibility of  ovulation  and  the  transport  of  the  ovum  in  the  normal 
manner,  and  consequently  sterility. 

When  metritis  pursues  its  course  without  being  aggravated  by  any 
of  these  comphcations,  it  terminates  like  all  inflammations  by  resolu- 
tion. The  latter  may  be  complete  or  incomplete.  Even  when  com- 
plete, the  inflammatory  symptoms  do  not  commence  to  decrease  for 
seven  or  eight  days,  and  cannot  disappear  under  a  fortnight.  Usually  it 
is  not  till  the  end  of  the  third  week  that  we  can  hope  for  the  disap- 
pearance of  the  evil.  Complete  resolution  cannot  be  depended  on 
before  the  return  of  the  next  menstrual  period.  If  it  occur  normally 
cure  may  be  considered  as  ensured.  If,  however,  fluxion  and  uterine 
congestion  produce  pain  and  especially  if  they  rekindle  fever,  resolu- 
tion is  not  complete ;  a  relapse  is  to  be  feared  or  the  transition  to  the 
chronic  state.  Incomplete  resolution  is  usually  the  consequence  of 
bad  treatment  or  want  of  prudence  on  the  part  of  the  patient,  as  for 
example,  rising  too  soon,  walking,  resuming  ordinary  work,  &c. ;  but 
it  depends  also  on  the  constitution  of  the  patients,  women  of  lym- 
phatic temperament,  weak  constitution,  deteriorated  organisation,  and 

1  Gazette  medicale  cle  Paris,  1835,  p.  444. — See  pi^  272,  273,  figs.  211,  212. 


486  UTEEINE    DISEASES    IN   DETAIL 

those  who  are  already  affected  with  some  disease,  especially  a  diathetic 
disease,  such  as  scrofula,  being  specially  disposed  to  it. 

The  cJironic  form  of  uterine  inflammation,  whether  it  result  from 
the  acute  state,  or  whether  it  have  assumed  this  form  from  the  begin- 
ning, may  recommence  under  the  influence  of  various  causes  especi- 
ally traumatic,  and  lead,  although  rarely,  to  one  of  the  fatal  termina- 
tions or  one  of  the  complications  of  the  acute  state.  Or  it  may 
persist  indefinitely^  producing  softening  of  the  organ,  favouring  the 
indefinite  duration  of  the  leucorrhoea,  facilitating  the  development  of 
granulations  and  fungosities,  causing  the  uterine  tissue  to  pass  from 
softening  to  total  or  partial  induration  by  the  organisation  of  the 
plasma  exuded  and  interposed  in  its  elements,  sometimes  producing  a 
simple  increase  of  nutrition  and  consequent  hypertrophy,  and  not 
apparently  capable  of  spontaneous  cure.  Cure  may  be  apparent,  i.e. 
an  amelioration  may  take  place,  so  far  as  disappearance  of  the  sub- 
jective symptoms  of  the  disease  is  concerned ;  and  patients  may  think 
themselves  perfectly  cured,  whilst  examination  shows  that  lesions  are 
still  considerable ;  this  improvement  continues  sometimes  for  years, 
till  under  the  influence  of  some  external  cause  all  the  former  sym- 
ptoms reappear  with  more  or  less  intensity.^  Even  when  cured, 
engorgement  and  other  ineffaceable  traces  of  its  existence  may  be  left 
behind.  The  principal  anatomical  cause  of  this  rarity  in  the  cure  of 
chronic  metritis  is  the  persistence  of  the  vascular  dilatation  kept  up  by 
too  long  a  congestion  and  by  the  loss  of  the  normal  tonicity  of  the 
arterial  and  venous  walls  which  is  the  consequence  of  it ;  therefore  it 
is  especially  this  particular  form  of  metritis  (with  venous  congestion) 
which  may  be  considered  incurable.  The  curability  of  the  majority 
of  other  forms,  after  a  more  or  less  prolonged  treatment  is  an  ascer- 
tained fact. 

Diagnosis — suljective  signs. — The  commencement  of  acute  metritis, 
especially  of  puerperal  metritis,  is  marked  by  more  or  less  intense  and 
prolonged  shivering.  This  shivering  may  be  wanting  in  non-puer- 
peral acute  metritis,  but  not  so  often  as  Aran  says.  It  is  followed  by 
fever,  often  by  the  suspension  of  the  lochia,  and  by  continuous  hypo- 
gastric pain,  differing  from  uterine  colics  and  extending  to  the  iliac 
regions,  especially  to  the  left.  Fever  is  never  absent  in  acute  metritis. 
"Whenever  the  pulse  exceeds  100  or  120,  we  must  be  on  our  guard  ; 
the  cause  of  the  fever  must  be  accounted  for  and  treated  from  the 
first.  If  this  fever  is  accompanied  by  erratic  shivering  and  later  on 
by  sweating  or  vomiting,  we  must  be  doubly  careful,  for  these 
symptoms  rarely  fail  to  announce  phlebitis. 

Often  the  local  phenomena  precede  the  general  symptoms.  Of  all 
these  phenomena  the  most  marked  is  hypogastric  pain — a  very  acute 
pain,  quite  different  from  the  uterine  colics  which  follow  delivery, 
being  continuous,  and  becoming  worse  every  hour,  occurring  in  non- 
puerperal acute  metritis  as  well  as  in  puerperal  metritis.  This  may  be 
accompanied,  especially  in  internal  metritis,  with  real  expulsive  colics, 
forcing  patients  to  roll  themselves  into  a  ball  to  prevent  all  tension  of 
'  Scanzoni,  op.  cit.,  p.  189,  et  seq. 


METRITIS  487 

the  abdominal  muscles,  which,  as  well  as  the  least  pressure,  suffices  to 
increase  the  pain.  Arterial  pulsation  is  also  often  present,  which  the 
physician  may  occasionally  ascertain  by  placing  the  finger  in  the 
utero- vaginal  sinus,  to  the  right  and  left  of  the  cervix,  as  deeply  as 
possible. 

Tliis  pain  is  propagated  into  the  iliac  regions,  especially  on  the  left 
side,  all  round  the  uterus,  to  the  whole  hypogastrium,  or  towards  the 
rectum,  the  vagina,  the  bladder,  according  to  whether  the  peritoneum 
or  the  neighbouring  organs  participate  most  in  the  inflammation.  It 
radiates  towards  the  groins,  the  thighs,  the  umbilicus,  the  sacrum  and 
the  loins.  It  may  or  may  not  be  accompanied  by  pelvic  heaviness, 
and  in  that  it  differs  from  congestive  pain.  The  patient  experiences  a 
burning  heat  in  the  hypogastrium,  as  well  as  at  the  vagina  and  vulva. 
This  heat  is  by  its  nature  and  intensity  characteristic  of  acute  metritis. 
There  is  no  discharge  from  the  vagina,  the  lochise  are  usually  sup- 
pressed ;  soon  afterwards  a  mucous  discharge  appears,  which  rapidly 
becomes  mucoso-purulent,  or  even  sanguinolent  in  cases  of  simple 
acute  metritis.  In  puerperal  metritis  the  discharge  is  grey,  purulent, 
often  foetid.  When  metritis  appears  in  the  midst  of  menstruation  the 
catamenia  cease  suddenly.  When  it  exists  before  the  arrival  of  the 
menses  it  is  aggravated  by  the  fluxion  which  the  menstrual  period 
brings  back,  all  the  more  so  that  there  is  more  frequently  suppression 
of  the  periodical  sanguineous  discharge  than  menorrhagia. 

The  neighbouring  symptoms  are  pain  in  micturition,  urine  red, 
scanty  and  scalding;  generally  constipation,  sometimes  a  glairy 
diarrhoea,  with  straining,  tenesmus  and  burning  pain. 

The  general  symptoms  are  :  fever,  which  never  fails,  and  which  lasts 
till  resolution  of  the  metritis,  or  till  it  has  passed  into  a  chronic  state ; 
anorexia,  foul  tongue,  thirst,  hiccough,  sometimes  vomiting,  which 
may  be  a  symptom  of  peritonitis.  Lastly,  more  serious  general 
symptoms,  a  small  as  well  as  frequent  pulse,  profuse  clammy  perspira- 
tion, delirium,  &c,,  may  be  added  to  the  preceding,  and  increase  the 
gravity  of  the  prognosis,  for  they  are  the  signs  of  very  serious  compli- 
cations, such  as  purulent  absorption  or  puerperal  fever.  The  same 
signs,  in  a  less  degree,  characterise  non-puerperal  acute  metritis. 

In  the  chronic  state  metritis  is  manifested  by  almost  identical  signs, 
though  less  serious,  especially  the  local  symptoms,  which  may  be  con- 
cealed by  the  predominance  of  general  symptoms,  occasionally  to  such 
a  point  that,  patients  may  be  mistaken  as  to  the  seat  and  nature  of 
their  malady.  However,  there  is  always  pain  in  the  regions  already 
indicated,  as  well  as  in  the  loins  and  its  various  radiations,  sometimes 
even  radiation  towards  the  coccyx,  known  as  coccygodynia  (I  have 
never  observed  it) ;  but  the  hypogastric  and  left  iliac  pains  are  the 
most  prominent.  This  left  iliac  pain  usually  accompanies  hypogastric 
pain,  and  sometimes  even,  when  metritis  has  passed  into  the  chronic 
state,  it  affects  the  patient  more  than  hypogastric  pain,  which  in  a 
measure  is  effaced  by  it.  It  is  difficult  of  explanation,  but  it  is  a  very 
frequent,  if  not  a  constant  fact ;  whether  it  is  that  the  rectum  or 
sigmoid  flexure  congests  the  left  appendages  more  than  the   right,  or 


488  UTEEINE    DISEASES    IN    DETAIL 

\bat  the  latter,  especially  the  ovary,  have  more  tendency  to  partici- 
pate in  inflammation,  as  in  the  male  orchitis  is  developed  more 
frequently  to  the  left,  or  that  the  fundus  of  the  uterus  being 
inclined  to  the  right,  produces  pain  by  the  dragging  of  the  left 
appendages. 

Pain  is  aggravated  by  pressure,  constriction,  walking,  sometimes  by 
the  least  shock,  e.g.  that  produced  by  a  false  step  or  going  down 
stairs.  In  all  cases  of  uterine  or  peri-uterine  inflammation  patients 
invariably  sit  down  cautiously,  and  instinctively  protect  the  hypogas- 
trium  from  the  smallest  shock.  The  pain  is  increased  still  more  by 
walking,  leaping,  the  shaking  of  a  carriage,  riding,  sudden  movements, 
coitus,  especially  when  the  penis  impinges  too  strongly  against  the 
cervix.  It  is  also  increased  by  constipation  and  by  fulness  of  the 
rectum  and  bladder.  This  pain  is  continuous  and  dull ;  it  is  heavy, 
and  accompanied  by  a  feeling  of  discomfort  in  the  pelvic  cavity,  weight 
at  the  perineeum,  anus  and  sacrum;  but  it  is  also  accompanied  by 
shooting  pains,  like  those  which  characterise  the  pain  of  acute  metritis, 
recurring  at  longer  or  shorter  intervals,  and  with  arterial  pulsation 
often  felt  by  the  patients,  and  sometimes  by  the  physician  to  the  right 
or  left  of  the  cervix.  There  is  a  persistent  and  uncomfortable  heat 
in  the  abdomen,  and  especially  in  the  uterine  region,  often  extending 
to  the  vulva,  with  vulval  pruritus,  &c. 

Sometimes  the  vulva  and  vagina  are  dry;  at  other  times  there  is 
leucorrhoea^  rarely  abundant,  muco-purulent  or  quite  purulent,  more 
or  less  acrid,  but  always  less  so  than  in  the  acute  form.  It  is  seldom 
accompanied  by  vaginitis :  the  latter  usually  only  comphcates  the 
superficial  inflammation  of  the  cervix,  which  is  a  natural  extension  of 
it.  Sometimes  there  are  no  menstrual  disorders,  excepting  slight 
pains  at  the  monthly  period.  At  other  times  there  are  dysmenorrhcea, 
uterine  colics  at  every  monthly  period,  increased  hypogastric  and  in- 
guinal pains,  as  well  as  lumbar  pain.  At  other  times  there  are  dis- 
orders, consisting  chiefly  in  irregularities ;  irregularity  in  the  monthly 
period  and  in  the  quantity  of  blood  evacuated.  With  regard  to  the 
irregularity  of  recurrence,  the  menses  sometimes  recur  too  seldom 
(symptom  of  parenchymatous  metritis),  sometimes  too  frequently 
(common  symptom  of  endometritis).  With  regard  to  the  irregular 
quantity,  they  may  be  diminished  or  suppressed  (symptom  of  paren- 
chymatous metritis),  or  increased  to  the  point  of  producing  menor- 
rhagia  and  even  metrorrhagia  (phenomena  occurring  in  cases  of  general 
metritis^  and  especially  in  those  of  endometritis) , 

Sterility  is  an  almost  unavoidable  consequence  of  metritis :  some- 
times mechanical,  from  obliteration  of  the  orifices,  adhesions,  fixity^ 
vicious  positions  contracted  by  the  Fallopian  tubes,  the  ovaries  and 
the  uterus  in  their  reciprocal  relations,  or  in  their  connections  with 
other  organs ;  often  a  vital  consequence,  if  I  may  so  express  myself, 
from  the  condition  in  which  the  state  of  inflammation  places  the  uterus, 
rendering  it  impossible  for  it  to  accomplish  the  numerous  and  delicate 
physiological  acts  which  preside  at  fecundation,  conception,  pregnancy. 
Chronic  metritis  is  therefore  an  obstacle  to  conception.     This  rule  has 


METRITIS  489 

only  a  few  exceptions ;  and  even  then  pregnancy  is  interrupted  at  an 
early  stage  by  an  abortion. 

Is  it,  however,  possible  for  metritis  to  be  developed  or  increased 
during  the  course  of  a  pregnancy  ?  At  first  sight  it  would  seem  that 
it  was  not ;  and  the  fact  is  that  inflammation  is  developed  very  rarely 
in  such  circumstances ;  I  have,  however,  collected  a  small  number  of 
examples.  I  have  seen  a  case  of  metritis  occur  at  the  beginning  of  a 
pregnancy  soon  producing  abortion,  and  followed  by  the  evacuation  of 
fetid  pus.  Purulent  infection  was  manifested  soon  afterwards  and 
the  patient  succumbed. 

The  neighbouring  symptoms    recall  those  of   acute   metritis    and 
uterine  congestion  :  on  the  side  of  the  rectum,  hEemorrhoids,  constipa- 
tion, with  fictitious  and  troublesome  desire  to  go  to  stool,  tenesmus, 
sometimes  even  glairy  enteritis ;  on  the  side  of  the  bladder,  frequent* 
desire  for  micturition  accompanied  by  heat,  &c. 

In  short  the  general  symptoms  are  often  so  developed  that  they 
throw  the  others  into  the  shade,  and  may  mislead  patients  as  to  the 
seat  and  reality  of  the  evil.  Patients  often  tell  their  physician  of 
their  weakness,  headaches  and  dyspepsia,  and  are  surprised  to  discover 
that  the  real  seat  of  the  trouble  is  the  womb,  and  that  these  trouble- 
some phenomena  which  have  tormented  them  and  made  them  lose  flesh 
for  so  many  months,  or  even  years,  are  only  symptoms  of  chronic 
metritis.  The  disorders  of  the  digestive  organs  are  vomiting,  anorexia 
and  especially  dyspepsia.  Nausea  may  be  considered  a  characteristic 
symptom  of  inflammation  of  the  body  of  the  uterus.  The  nervous 
troubles  assume  all  the  forms  of  hysteria,  not  that  they  depend  on  real 
hysteria,  which  may  though  seldom  coincide  with  chronic  metritis, 
but  because  the  alterations  of  the  functions  of  the  nervous  system, 
those  especially  of  which  the  uterus  is  the  starting-point,  most  fre- 
quently take  this  character.  These  are  abdominal  pains,  gastralgia, 
pharyngeal  constriction,  intercostal  neuralgia,  which  may  make  patients 
think  that  they  have  a  cardiac  or  pulmonary  disease,  headaches  or 
the  facial  neuralgia  of  a  more  or  less  limited  kind,  and  lastly  what  is 
called  the  hysterical  nail  [clou  liysteriqiie)  ;  visceral  neurosis  may  exist ; 
neuralgia  in  the  limbs  is  rare.  These  disorders  of  the  digestive  and 
nervous  systems  produce  impoverishment  of  blood,  ansemia,  chloro- 
ansemia  and  more  or  less  debility. 

Objective  sigtis. — Pain,  tumefaction,  heat,  redness,  all  the  objective 
signs  of  inflammation,  are  easily  seen  in  metritis,  and  as  they  help  to 
distinguish  metritis  from  other  morbid  states  of  the  uterus  with  which 
they  may  be  confounded,  it  is  important  to  be  able  to  determine  with 
precision  their  existence  in  the  inflamed  uterus. 

The  pain  is  well  marked ;  it  has  its  seat  in  the  uterus.  It  exists  in 
puerperal  and  non- puerperal  metritis,  in  acute  and  chronic  inflamma- 
tion, in  metritis  of  the  mucous  membrane  as  well  as  of  the  paren- 
chyma ;  in  the  latter  especially  the  diagnosis  of  it  is  important,  as  the 
absence  of  purulent  leucorrhoea  might  throw  doubts  on  the  existence 
of  the  metritis. 

Pressure  on  the  hypogastrium  and  left  iliac  fossa  allows  the  real 


490 


UTERINE    DISEASES  IN   DETAIL 


seat  of  pain  to  be  determined ;  whilst  pressure  exercised  with  the 
finger  on  the  body  or  neck  provokes  pain  in  the  uterus  to  the  exclusion 
of  all  the  neighbouring  parts.  The  association  of  hypogastric  palpa- 
tion with  vaginal  touch  is  necessary  to  determine  exactly  the  seat  and 
nature  of  the  pain.  It  is  important  to  distinguish  the  pain  elicited  by 
movements  and  transmitted  to  the  uterus  from  that  produced  by 
pressure  exercised  on  the  organ.  Very  often  pain  is  caused  by 
pressing  on  a  congested  or  deviated  uterus,  whilst  none  is  caused  by 
pressing  on  a  uterus  affected  with  chronic  inflammation,  especially  if 
owing  to  its  elevation  or  some  other  cause  it  is  not  easily  reached. 
Pressure  upon  the  cervix  from  the  finger  introduced  into  the  vagina, 
either  upwards  or  from  side  to  side,  will  often  give  great  pain, 
however  slightly  the  organ  is  congested,  deviated  or  flexed,  or  if  the 
appendages  or  neighbouring  organs  be  the  seat  of  some  disease.  If 
the  touch  is  practised  in  the  same  way  in  a  case  of  chronic  metritis  in 
a  woman  of  average  sensibility,  whose  peri-uterine  organs  are  in  good 
condition,  pain  may  not  be  elicited  ;  that  is  because  the  uterus  rises, 
swings  from  side  to  side  and  yields  easily  to  the  pressure  of  the  finger, 
and  does  not  encounter  any  painful  organ  in  its  movements.  If,  on 
the  contrary,  the  uterus  is  retained  in  the  pelvis  by  methodic  hypo- 
gastric pressure  whilst  the  anterior  or  posterior  surface  of  the  cervix 
is  reached  by  vaginal  or  rectal  touch,  the  uterus  is  held  between  the 
hand  and  finger,  and  it  alone  is  subjected  to  pressure.  Now,  even  in 
cases  of  chronic  metritis,  whilst  pressure  on  all  the  neighbouring  points 
fails  to  produce  pain,  that  exercised  on  the  uterus  determines,  on  the 
contrary,  sudden  acute  pain,  which  extorts  a  cry  from  the  patient,  and 
which  is  comparable  to  that  produced  by  the  slightest  pressure  on  an 
abscess  or  any  inflamed  and  painful  part.  This  precision  in  determining 
the  seat  of  pain  is  of  first  importance  in  the  diagnosis  and  treatment  of 
chronic  metritis. 


Fig.  314. — Cervix  uteri  in  a 
virgin  (after  H.  Bennet). 


Fig.  315. — Cervix  uteri  in  a  virgin,  in- 
flamed and  ulcerated,  normal  linear 
form  (after  H.  Bennet). 


The  tumour  or  increased  size  of  the  organ  is  easily  ascertained  by 
the  same  means.  In  puerperal  metritis  this  tumefaction  is  consider- 
able :  the  uterus  is  large  at  the  time ;  when  inflammation  begins  retro- 
evolution  is  arrested,  and  the  afflux  of  fluids  contributes  to  preserve 
the  dimensions  that  it  was  on  the  point  of  losing.     In  non-puerperal 


METRITIS  491 

metritis,  acute  or  chronic,  the  uterus  in  spite  of  its  tumefaction  does 
not  always  pass  beyond  the  pubis.  Sometimes,  however,  in  forty- 
eight  hours  it  may  reach  the  size  of  an  ostrich  egg.  It  is  important 
to  notice  that,  in  spite  of  this  increase  of  size,  the  uterus  preserves  its 
mobility.  This  tumefaction  determines  a  swelling  in  the  hypogastrium, 
varying  with  the  patient  and  the  species  of  metritis.  In  parenchy- 
matous metritis  the  abdomen  is  moderately  distended.  Whilst  in 
endometritis  there  is  a  distension  of  the  lower  half  of  the  abdomen 
due  to  reflex  tympanitis  very  variable  in  intensity.  The  tumefaction 
of  the  cervix  and  body,  ascertained  by  the  combination  of  rectal  and 
vaginal  touch  with  hypogastric  palpation,  leave  no  doubt  as  to  the 
increased  size  of  the  uterus.  This  tumefaction  is  sometimes  so  great 
as  to  cause  descent  of  the  organ.  It  may  be  measured  by  seizing 
the  uterus  between  the  finger  of  one  hand  introduced  into  the  vagina 
and  the  palmar  surface  of  the  other  hand  pressing  the  hypogastrium 
methodically.  Lastly,  the  vaginal  portion  of  the  neck  is  rounded, 
projecting,  and  the  os  gaping  ;  this  tendency  is  specially  remarkable  in 
the  case  of  metritis  of  the  cervix.  In  the  virgin,  the  cervix  although 
tumefied,  sometimes  preserves  an  almost  conical  form ;  even  when  the 
inflammation  does  not  reach  it,  it  does  not  share  in  the  increased  size 
of  the  rest  of  the  organ,  so  that  by  simple  inspection  we  might 
be  misled  as  to  the  real  state  of  the  uterus.  The  os,  which  is  ex- 
ceptionally circular  on  an  inflamed  virginal  cervix,  is  increased  in  size, 
and  the  inequality  in  the  tumefaction  of  the  tissue  circumscribing  it 
gives  rise  to  kinds  of  radiating  folds  starting  from  the  centre  and 
diverguig  at  a  short  distance  from  the  border.  In  the  married  woman 
it  is  rounder,  assuming  the  form  of  a  cone  with  its  base  downwards  ; 
its  lips  are  projecting  and  irregular.  In  the  multipara  it  is  infinitely 
more  marked,  and  not  only  is  the  circumference  of  the  cervix  irregular, 
but  it  is  marked  by  deep  cicatrices,  traces  of  lacerations  which  have 
occurred  at  delivery.^ 

The  heat  is  intense,  especially  in  newly- delivered  women,  in  whom 
it  may  be  perceived  by  placing  the  hand  on  the  abdomen.  In  other 
cases  of  acute  metritis  it  may  be  less ;  but  if  we  place  the  hand  flat 
on  the  abdomen  above  the  umbilicus,  descending  gradually  to  the 
pubis  so  as  to  pass  over  the  hypogastric  and  iliac  regions  slowly,  we 
cannot  fail  to  perceive  it,  especially  at  the  hypogastrium ;  but  it  is 
much  more  appreciable  in  the  vagina  and  on  the  vaginal  portion  of 
the  cervix.  Sometimes  it  is  accompanied  by  dryness  ;  at  other  times, 
on  the  contrary,  by  a  more  or  less  abundant  secretion. 

The  redness  is  not  easily  perceived  at  first ;  for  there  are  patients 
to  whom  touch  is  so  painful  as  to  be  almost  impracticable ;  and  there- 
fore the  introduction  of  the  speculum  is  impossible  for  the  time. 
However,  these  cases  are  rare,  and  we  should  have  recourse  to  these 
means  of  exploration  as  soon  as  possible,  in  the  first  place,  because 
they  are  necessary  to  confirm  the  diagnosis,  and  because  as  regards 
treatment,  it  is  important  to  know  whether  we  have  to  do  with  a  case 

'  Fig.  312,  p.  471,  will  give  an  idea  of  the  aspect  which  tlie  cervix  f  requentlj 
presents  under  such  circumstances. 


492  UTEEINE    DISEASES    IN    DETAIL 

of  metritis^  peritonitis^  peri-uterine  phlegmon,  &c. ;  in  the  second 
place,  because  we  cannot  otherwise  apply  the  most  efficient  means  of 
treatment,  viz.  leeches.  Besides,  by  taking  the  precautions  indicated 
elsewhere  in  introducing  the  speculum  it  can  be  used  without  much 
pain,  and  the  local  application  of  leeches  will  alleviate  the  suffering 
sooner  than  anything  else.  The  redness  is  less  dark  and  venous  than 
in  congestion,  but  it  is  very  pronounced  and  accompanied  by  a  dispo- 
sition of  the  mucous  membrane  to  bleed  on  the  slightest  friction.  The 
blood  is  often  red,  vermillion,  very  different  from  that  which  flows 
from  the  congested  cervix.  Sometimes  without  having  even  wiped  the 
cervix  we  perceive  the  surface  deprived  of  epithelium,  red,  bleeding, 
with  real  erosions,  exulcerations,  and  even  ulcerations  of  variable 
form,  granular  fungus,  &c.  When  the  vaginal  portion  of  the  cervix 
is  not  diseased,  but  when  the  mucous  membrane  of  the  uterine  cavity 
is  inflamed,  and  when  this  inflammation  extends  to  near  the  orifice,  if 
we  look  through  the  os  (the  eversion  of  the  swollen  irregular  lips 
facilitates  the  observation)  we  shall  see  that  this  mucous  membrane 
is  of  a  bright  red,  contrasting  singularly  with  its  usual  colour. 

When  the  metritis  is  accompanied  by  more  or  less  intense  vaginitis, 
the  surface  of  the  vagina  touching  the  cervix  is,  like  it,  bright  red 
and  covered  with  small  granulations  either  confluent  (granular  vagini- 
tis) or  discrete  (folhculitis  of  the  cervix)  :  whilst  redness,  project- 
ing papillse,  and  superficial  erosions  may  extend  to  the  internal  surface 
of  the  labia  majora. 

A  leucorrhoeic  discharge,  not  only  vaginal  but  uterine,  may  or  may 
not  accompany  metritis,  and  we  must  beware  of  looking  upon  this 
leucorrhoea  as  well  as  upon  the  other  symptoms  just  referred  to  as  a 
real  sign  of  metritis ;  for  all  these  symptoms  may  exist  without  it 
and  it  may  exist  without  them.  With  regard  to  the  leucorrhoea  we 
must  ascertain  if  the  discharge  is  superficial  and  due  to  granulations, 
follicular  or  otherwise,  of  the  vaginal  portion ;  or  if  it  is  profound, 
whether  it  comes  from  the  cavity  of  the  neck  or  the  body ;  if  mucous, 
thick  and  viscous  (coming  from  the  neck) ;  or  if  clear,  aqueous,  sanguino- 
lent,ormuco-sanguineous  (coming  from  the  body), which  maybe  due  to  a 
catarrh,  to  simple  fluxion,  &c. ;  or  if  it  is  muco-purulent  or  purulent 
mixed  with  globules  of  blood,  or  yellowish  white,  very  yellow,  yellow 
green,  and  more  or  less  creamy  (which  is  often  a  symptom  of  metritis, 
especially  of  internal  metritis). 

As  a  rule  we  must  abstain  from  using  the  sound  :  it  is  useless,  and 
may  be  dangerous.  We  run  the  risk  of  finding  a  uterus  at  the  period 
of  inflammatory  softening,  and  by  pushing  the  sound  in  a  direction 
not  exactly  that  of  the  axis  of  the  organ  may  partially  perforate  the 
tissue.  It  is  only  in  doubtful  cases  of  chronic  metritis  limited  to  the 
body  or  in  cases  of  chronic  endometritis  that  the  use  of  the  sound  is 
practicable,  and  only  then  with  great  prudence.  It  measures  the 
increased  length  of  the  uterus,  which  sometimes  reaches  3|  or  3| 
inches,  and  also  the  increased  capacity  of  the  organ,  the  instrument 
being  easily  turned  in  every  direction,  owing  to  the  excentric  hyper- 
trophy usually  observed  in  metritis,  especially  in   chronic   internal 


METRITIS  493 

metritis.  At  the  same  time  it  allows  of  the  increased  sensibility  of  the 
organ  being  perceived;  for  its  introduction  is  not  made  without 
causing  sharp  pain  especially  in  passing  the  os  internum.  It  gives  an 
idea  of  the  facility  with  which  the  mucous  membrane  bleeds ;  for  in 
'this  case  it  is  often  accompanied  by  a  comparatively  abundant  hsemor- 
rhage,  which  is  presumptive  of  the  existence  of  uterine  fungosities, 
especially  when  the  sound  encounters  difficulties  in  traversing  the 
internal  surface  of  the  organ. 

Abscess  of  the  parenchyma  of  ike  uterus. — The  formation  of  pus  and 
the  presence  of  an  abscess  in  the  uterine  tissue  may  be  observed  after 
abortion,  delivery  or  operations  performed  on  the  uterus  and  genital 
-organs,  but  it  is  so  rare  after  non-puerperal  acute  metritis  that  it  has 
been  denied.  I  do  not  say  that  a  concomitant  catarrh  may  not  be 
mistaken  for  it ;  nevertheless,  the  following  facts  seem  to  me  very 
conclusive.  Frederick  Bird  ^  gives  the  case  of  a  woman  of  thirty- 
seven  who  succumbed  to  chronic  metritis ;  the  fundus  was  three  times 
its  normal  thickness;  an  abscess  developed  in  the  posterior  wall 
opened  by  a  short  and  narrow  passage  into  the  rectum ;  it  did  not 
^  communicate  with  the  uterine  cavity.  Scanzoni  ^  relates  another  case 
in  a  young  woman,  after  a  sudden  suppression  of  menstruation; 
violent  metritis  followed,  treated  for  eight  days  without  obtaining  any 
amelioration;  on  the  contrary,  sensibility  of  the  uterine  region 
increased,  shivering  occurred  frequently,  and  a  tumour  of  the  size  of 
an  egg,  moderately  resistant  and  easily  defined,  was  developed  above 
the  horizontal  portion  of  the  right  pubis.  Symptoms  of  violent  peri- 
tonitis appeared  suddenly  on  the  twenty-second  day  to  which  the 
patient  succumbed  on  the  thirty-first  day.  The  autopsy  showed  the 
cause  of  death  to  be  the  rupture  of  an  abscess  of  the  size  of  a 
goose's  egg,  situated  in  the  right  and  upper  portion  of  the  uterus, 
the  pus  from  which  had  made  a  way  for  itself  through  the  ex- 
ternal layers  of  the  substance  of  the  uterus  and  its  peritoneal 
envelope.^ 

In  exceptional  circumstances  the  malady  not  only  assumes  a 
'  chronic  form,  but  the  purulent  collection  may  reach  very  considerable 
proportions.*  Uterine  abscesses  may  be  opened  artificially  or  spon- 
taneously into  the  uterine  cavity,  the  rectum,  the  vagina,  the  ab- 
dominal cavity,  the  bladder,  or  even  through  the  abdominal  parietes, 
previously  united  to  the  uterus  by  means  of  adhesions.^ 

'  Gaz.  med.  de  Paris,  1843,  p.  645. 

-  Op.  cit.,  p.  159. 

'  Lados  has  also  published  a  fact  of  this  kind,  Gaz.  medicale  de  Fans,  1839, 
p.  605. 

*  Hervez  de  Chegoin,  SocUte  de  chirnrgie,  Dec.  2,  1868. 

5  Besides  the  case  just  related,  in  which  probably  a  phlegmon  was  formedin 
the  pregnant  uterus,  I  have  collected  some  other  undoubted  cases  of  uterine 
abscess:  one  opened  into  the  uterine  cavity,  another  into  the  vagina  in  the 
middle  of  the  posterior  cervical  lip,  another  into  the  utero- vaginal  groove  of 
the  posterior  lip,  another  into  the  anterior  groove,  and  three  others  laterally. 
Only  it  was  doubtful  (especially  with  regard  to  the  latter)  whether  these  were 
uterine  abscesses ;  a  phlegmon  of  the  broad  ligament  might  be  suspected.  I 
have  only  diagnosed  a  uterine  abscess  when  the  sound  reached  a  centre  evidently 


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496  UTEEINE  DISEASES   IN   DETAIL 

When  a  uterine  abscess  is  formed,  there  may  be  much  difficulty  in 
determining  the  nature  of  the  tumour  due  to  this  cause.  In  addition 
to  the  presence  of  the  tumour,  there  is  intense  fever,  with  irregu- 
larities, sometimes  shivering,  perspiration  and  all  the  other  symptoms 
denoting  the  formation  of  pus.  Scanzoni  thinks  that  diagnosis  is 
only  possible  when,  after  having  observed  the  symptoms  of  acute 
metritis,  the  presence  of  a  tumour  of  rapidly  increasing  size  at  first 
hard  and  then  fluctuating  is  discovered  through  the  superior  vaginal 
wall  or  the  anterior  abdominal  wall.  But  even  in  such  cases  we  must 
admit  that  diagnosis  may  remain  doubtful  till  the  pus  has  spontane- 
ously made  a  passage  for  itself  or  till  its  presence  has  been  proved  by 
an  exploratory  puncture,  which  should  only  be  made  with  great  pre- 
caution. 

Abcesses  of  the  uterus,  formed  by  a  purulent  collection  within  the 
uterine  wall  or  between  the  uterus  and  its  peritoneal  covering  are 
closely  connected,  by  their  symptoms  and  general  course,  with  pelvic 
abscesses.  The  only  difference  is  that  in  cases  of  the  former  kind,  the 
tumour  appears  to  be  a  tumefaction  of  the  uterus  itself,  more  limited 
and  more  circumscribed  than  in  those  of  the  second  series. 

The  prognosis,  always  doubtful,  may  be  very  serious.  The  treat- 
ment is  that  of  acute  metritis.  If  the  abscess  is  accessible  to  the 
bistoury  an  exploratory  puncture  may  be  made,  and  when  it  is  found 
to  contain  pus  it  may  be  opened. 

Differential  diagnosis. — Tlie  differential  diagnosis  of  metritis,  espe- 
cially of  acute  metritis,  is  usually  easy;  but  it  is  not  always  so. 
The  accompanying  table  sums  up  the  differential  diagnosis  between 
metritis  and  the  other  uterine  maladies  which  may  be  confounded 
with  it. 

The  other  uterine  disorders  which  must  be  distinguished  from  me- 
tritis are  :  hysteralgia,  hematometria,  hydrometria,  pregnancy,  flexions, 
uterine  catarrh,  ulcerations,  fibromata,  polypi,  cancer.  The  elements 
of  differential  diagnosis  will  be  given  in  the  description  of  each. 

2.  Maladies  of  the  appendages  and  peri-titerine  maladies — infiam- 
mations  and  tumours  of  the  Fallopian  tubes  and  ovaries. — There  is  no 
tumefaction  and  no  uterine  pain  unless  the  inflammation  extends  to 
the  womb ;  but  there  is  a  tumour  behind  the  organ  or  on  one  side  of 
it,  which  is  usually  accessible  to  the  finger  in  the  utero-vaginal  sinus. 
The  seat  of  this  tumour,  which  is  usually  limited  to  one  side,  is  espe- 
cially observed  when  vaginal  touch  is  associated  with  palpation. 

Peri-uterine  inflammation. — The  uterine  tissue  is  not  painful  to 
pressure ;  but  we  cause  acute  pain  if  we  try  to  move  the  womb,  or 
press  on  the  tumour  formed  behind  or  around  it ;  the  uterus  itself  is 
immovable.  This  immobility  is  a  sign  of  great  importance,  and  con- 
trasts with  the  mobility  which  the  uterus  preserves  in  metritis. 

Hematocele  is  developed  rapidly  as  a  rule,  and  is  accompanied  with 
suppression  of  the  menses.     There  are  general  symptoms  of  hsemor- 

contained  in  a  segment  of  the  organ,  or  when  an  injection  could  not  apparently 
reacli  the  peripheric  portions.  In  this  way  it  is  possible  to  diagnose  with 
precision. 


METRITIS  497 

rhage  and  peritonitis.  Tumour  behind  or  on  one  side  of  the  womb, 
raising  the  vagina.  Uterus  displaced,  usually  upwards  behind  the  pubis, 
and  immovahly  fixed. 

Peritonitis. — Acute  abdominal  pain  on  the  slightest  contact. 
Bilious  green  vomiting,  hiccough,  abdominal  distension.  Face  drawn 
and  anxious,  ejes  sunk,  pulse  frequent,  small,  abdominal  in  character, 
extremities  cold,  &c.  Neuralgia,  whether  lumbo-abdominal  or  ileo- 
sacral,  is  rarely  accompanied  by  fever,  is  situated  almost  always  on 
one  side,  and  presents  well  marked  and  characteristic  joa^M/M^  spots. 

Treatment  of  metritis  ought  to  be  energetic :  essentially  antiphlo- 
gistic in  acute  metritis,  equally  antiphlogistic  in  the  commencement  of 
chronic  metritis,  the  complications  being  treated  at  a  later  period,  the 
principal  aim  being  to  regulate  the  uterine  functions  and  restore  the 
constitution. 

Treatment  of  acute  and  subacute  metritis. — It  consists  in  blood- 
letting, the  use  of  emollients,  revulsives  and  sedatives. 

I.  General  bloodletting  may  be  resorted  to,  but  I  think  it  has  been 
abused.  Blood  should  only  be  drawn  from  the  arm  in  cases  of  acute 
metritis  unless  the  patient  be  very  plethoric  or  the  case  otherwise 
exceptional.  Bloodletting  should  be  essentially  revulsive,  and  conse- 
quently performed  according  to  the  rules  of  revulsion,  i.e.  at  the 
commencement,  if  the  fluxion  is  strong  or  imminent,  or  immediately 
before  the  monthly  period,  or  after  local  sanguineous  evacuations  have 
prepared  the  mobilisation  and  revulsion  of  fluxion  considered  as  an 
element  of  the  inflammation  itself.  In  no  case  should  the  bloodletting 
be  spoliative,  especially  in  chronic  metritis.  "We  must  remember  that 
the  majority  of  such  patients  would  be  the  better  for  more  blood,  and 
that  when  any  is  abstracted  it  is  to  put  a  stop  to  the  fulness  of  the 
organ,  or  give  another  direction  to  the  blood,  but  never  with  the 
object  of  diminishing  its  quantity.  We  must  on  the  contrary  hasten 
to  repair  the  loss  by  means  of  tonics  and  iron,  if  we  would  ensure  any 
good  results  from  bleeding. 

The  application  of  leeches  or  cupping  glasses  to  the  hypogastrinm 
or  inner  surface  of  the  thighs  is  indicated  when  there  is  not  only 
metritis,  but  inflammation  of  the  neighbouring  parts  of  the  peritoneum. 
We  sometimes  require  to  have  recourse  to  them  when  the  narrowness 
and  sensitiveness  of  the  vagina  make  the  introduction  of  the  speculum 
impossible,  as  is  usually  although  not  always  the  case  in  virgins.  In 
puerperal  metritis,  when  the  uterus  has  just  been  depleted  by  the  loss 
of  blood  following  delivery,  leeches  applied  to  the  abdomen  produce  a 
salutary  derivation.  From  fifteen  to  twenty-five  should  be  applied 
several  times.  If  after  two  or  three  days  pain  still  continues  another 
application  should  be  prescribed,  unless  the  state  of  the  pulse  abso- 
lutely forbids  it,  for  in  some  cases  it  causes  the  pain  and  tumefaction 
of  the  uterus  to  disappear  as  if  by  enchantment.  In  this  way  puer- 
peral metritis  may  in  a  few  days  yield  to  energetic  and  well-directed 
treatment. 

The  application  of  leeches  to  the  cervix  is  preferable  to  general 
bleeding  in  simple  metritis,  whether  acute  or  chronic ;  it  alleviates  the 

32 


498  UTERINE    DISEASES    IN  DETAIL 

pain  at  once  and  weakens  less.  In  chronic  metritis  it  may  be  advisable 
to  repeat  the  application  several  months  successively  till  pain  on 
pressure  has  ceased  or  diminished  considerably.  These  sanguineous 
emissions  are  essentially  depletive;  they  have  a  decisive  action  on 
pains  experienced  by  patients,  and  the  immediate  effect  is  prodigious ; 
but  the  quantity  of  blood  drawn  should  be  considerable,  and  this  effect 
should  be  aided  by  that  of  intestinal  and  cutaneous  derivatives  and  re- 
vulsives. Yirchow^  rightly  says :  "  As  a  rule  local  bloodletting  should 
not  be  considered  as  a  direct  and  sufficient  antiphlogistic  means,  but 
rather  as  a  preparatory  one.  Its  action  is  only  transitory ;  but  when 
used  opportunely  it  prepares  for  the  action  of  other  remedies."  Lastly, 
scarifications  on  the  vaginal  portion  of  the  necJc  also  cause  direct  san- 
guineous evacuation.  We  are  obliged  to  have  recourse  to  them  in 
patients  who  are  ansemic  or  disposed  by  a  kind  of  hsemorrhagiparous 
diathesis  to  profuse  hsemorrhages,  or  when  inflammatory  congestion 
does  not  go  beyond  the  cervix,  or  when  the  lips  of  the  inflamed  neck 
are  covered  with  erosions,  ulcerations  or  papillary  or  follicular  granu- 
lations. Yirchow  makes  the  just  remark  that  scarifications  do  not  act 
exactly  like  leeches.  By  means  of  scarifications  we  penetrate  into  the 
interior  of  the  inflammatory  centre  and  cut  the  vessels  directly.  In 
this  way  we  obtain  not  only  direct  depletion  of  the  internal  tissues  and 
the  evacuation  of  exudations  which  are  in  process  of  formation,  but 
we  apply  the  most  energetic  irritation  (traumatic)  to  the  walls  of  the 
vessels,  and  thus  provoke  their  contraction  as  well  as  arrest  the  circula- 
tion for  a  long  time. 

II.  Before  resorting  to  revulsives  which  follow  the  application  of 
leeches  we  should  have  recourse  to  emollients  employed  even  before 
and  simultaneously  with  bleeding.  In  acute  metritis  a  severe  diet 
must  be  prescribed,  absolute  confinement  to  bed,  the  dorsal  decubitus 
with  the  head  flexed  on  the  trunk,  the  legs  on  the  thighs  and  the 
thighs  on  the  pelvis,  prolonged  tepid  baths,  general  at  first,  and  then 
sitz-baths,  emollient  and  narcotic  cataplasms,  fomentations  with  a  de- 
coction of  poppy-heads  and  belladonna,  enemata,  emollient  at  first 
afterwards  laxative,  injections  of  liquid  cataplasms,  to  remain  some  time 
in  the  vagina  (Valleix),  baths  or  fomentations  of  the  cervix  (Melier), 
emollient  injections  (tepid  milk,  mixture  of  oil  and  water,  decoction  of 
,toauve,  &c.),  narcotic,  and  when  necessary  detersive  injections  and 
better  still,  continuous  hot  irrigations,  either  in  the  bath  or  in  bed  by 
means  of  the  double  vaginal  irrigator,  or  on  the  bidet  with  the  hydro- 
clyse.     All  these  means  tend  to  favour  the  action  of  bloodletting. 

It  is  essential  that  the  baths,  irrigations  and  injections  should  be 
hot  (35°  to  40°  C. ',  95°  to  105°  P.)  at  the  commencement  of  inflam- 
mation. They  act  by  temperature,  imbibition,  moistening  of  the 
tissues,  and  by  their  emollient  or  sedative  principles,  and  by  the  clean- 
liness which  they  keep  up  in  the  vagina  and  on  the  cervix,  by  washing 
away  the  acrid  secretions,  the  irritating  mucous  discharges  from  the 
uterus.  The  continuous  irrigations  are  especially  useful,  which  the 
patient  may  suspend  and  resume  from  time  to  time  during  the  day. 
^  Kanctibuch  der  spec.  Path.  u.  Therapie.  Erlangen,  1854,  Bd.  i,  S.  84. 


METRITIS  499 

Emmet  recommends  hot  injections  in  place  of  tepid  or  cold  ones,  as  an 
excellent  means  of  restoring  tone  (bj  reflex  action)  to  the  veins  that 
have  lost  it,  and  of  dissipating  the  venous  congestion,  which  is,  in  his 
opinion,  the  essential  element  of  this  so-called  inflammation. 

In  cases  of  puerperal  metritis,  when  the  abundant  leucorrhoea 
becomes  sanious,  and  gangrenous  residues  are  added  to  the  pus,  the 
injections  should  be  made  disinfectant,  detersive  and  antiseptic,  by 
adding  quinine,  chloride  of  lime,  coal  tar,  carbolic  acid,  or  permanga- 
nate of  iron. 

In  proportion  as  the  acute  character  and  the  accidents  thereby  pro- 
voked diminish  or  disappear  and  the  metritis  passes  into  the  chronic 
state  or  shows  a  tendency  to  resolution,  the  temperature  of  the  injec- 
tions should  be  lowered  considerably.  Irrigations  with  tepid  and  even 
cold  water  in  sitz-baths  are  at  that  time  useful.  They  should  be 
repeated  twice  a  day  for  half  an  hour  or  an  hour  each  time. 

III.  Among  revulsives  repeated  purgatives  hold  undoubtedly  the 
first  place.  When  the  inflammation  is  violent  and  is  propagated  to 
the  peritoneum,  or  when  it  is  manifested  during  the  puerperal  state, 
mild  laxatives  are  preferable.  Castor  oil  besides  acting  as  such  keeps 
up  a  slight  revulsion  on  the  digestive  canal  without  exposing  it  to  in- 
flammation. Calomel  is  recommended  with  the  same  object.  Like 
Aran  I  prescribe  calomel  in  doses  of  from  1^  to  3  grains,  repeated 
every  twenty-four  hours,  but  without  allowing  it  to  affect  the  gums  or 
produce  mercurial  action  in  the  mouth,  which  can  always  be  prevented 
by  using  a  saturated  solution  of  chlorate  of  potash  as  a  gargle  and  wash- 
ing out  the  mouth  after  meals.  Mercurial  frictions  may  be  used  simul- 
taneously with  calomel  or  alone.  They  form  one  of  the  best  means  of 
subduing  acute  or  chronic  metritis.  Even  in  puerperal  metritis  the  fre- 
quent and  abundant  application  of  mercurial  ointment,  pure  or  with 
the  addition  of  a  twentieth  part  of  extract  of  belladonna,  has  an 
undoubted  effect.  In  the  acute  stage  we  must  not  |fear  to  use  5j 
or  more  in  the  day,  and  to  keep  it  on  for  some  days,  unless  a  miliary 
eruption  be  produced  by  the  mercury.  Purgatives,  in  addition  to 
chlorate  of  potash  used  as  a  gargle  as  well  as  internally,  prevent  saliva- 
tion. After  every  mercurial  application  a  large  hot  linseed  poultice 
made  with  the  decoction  of  poppy- heads  is  placed  on  the  abdomen,  if 
the  patient  can  bear  it.  In  chronic  metritis  I  continue  the  mercurial 
frictions  for  a  long  time,  but  in  small  doses,  not  as  antiphlogistics  but 
as  resolvents.  Every  evening  the  patient  should  apply  the  ointment 
to  the  abdomen,  groins,  and  to  the  upper  portion  of  the  inside  of  the 
thighs ;  over  this  she  lays  a  piece  of  linen  covered  with  cotton  wool 
and,  when  moisture  of  the  skin  is  desired,  oil  silk  or  waterproof  above, 
the  whole  being  easily  kept  in  place  by  a  small  pair  of  knitted  swim- 
ming drawers,  which  also  prevents  the  patient's  linen  from  being 
soiled.  The  resolvent  effect  of  this  treatment  is  wonderful.  To  return 
to  purgatives,  I  ought  to  add  that  in  a  great  number  of  cases  laxatives 
are  not  sufficient.  In  simple  acute  metritis,  after  applying  leeches  to 
the  cervix,  a  purgative  is  indicated.  Care  must  be  taken  to  repeat  the 
leeches  till  the  sanguineous  evacuation  has  been  sufficient ;  but  when- 


500  UTERINE   DISEASES   IN   DETAIL 

ever  the  depletive  effect  is  produced  and  pain  alleviated  recourse 
must  be  had  to  a  purgative  the  following  day.  If  the  patient  can  bear 
a  strong  purgation  it  need  not  be  feared,  and  may  be  repeated.  Epsom 
or  Glauber's  salts,  seidlitz  water,  rhubarb  and  senna,  castor  oil  with 
the  addition  of  one  or  two  drops  of  croton  oil,  produce  a  strong  re- 
vulsion on  the  digestive  canal  very  favorable  to  the  resolution  of  the 
inflammation.  This  should  be  repeated  after  every  application  of 
leeches,  especially  in  chronic  metritis.  I  may  also  mention  ipe- 
cacuanha, strongly  recommended  by  Trousseau  in  subacute  metritis 
depending  on  the  puerperal  condition ;  according  to  Pajot  also  it  is 
an  admirable  medicament. 

The  cutaneous  revulsives  most  frequently  employed  are  blisters. 
They  may  be  applied  to  the  inner  surface  of  the  thighs  or  to  the  calvps 
after  bleeding,  purgatives  and  mercurial  frictions.  Usually  they  are 
applied  to  the  hypogastrium  and,  when  repeated,  produce  excellent 
effects ;  but  they  act  more  efficiently  against  the  complications  of 
metritis,  peri-uterine  inflammation,  ovaritis,  &c.,  than  against  metritis 
itself.  They  are  equally  useful  in  acute  and  chronic  metritis.  Later 
on,  painting  with  croton  oil,  antimonial  ointment  or  tincture  of  iodine 
may  be  substituted. 

IV.  .A  last  indication  of  antiphlogistic  treatment  properly  so  called 
is  to  soothe  pain.  If  it  has  not  yielded  to  leeching,  and  if  the  nervous 
element  predominates  after  bleeding,  sedatives  and  narcotics  should 
be  resorted  to.  Small  enemata  with  10  or  20  drops  of  laudanum, 
opium  suppositories,  blisters  sprinkled  with  morphia,  frictions  with 
various  sedative  liniments,  and  lastly  opium  or  morphia  in  hypodermic 
injections,  may  be  administered  according  to  the  case.  Even  in  puer- 
peral metritis  about  |  of  a  grain  of  opium  may  be  given  in  a  day.  When 
patients  suffer  much  the  dose  may  be  increased  and  continued  till  pain 
ceases ;  f  of  a  grain  of  Ext.  Opii  can  easily  be  taken  every  six  hours ; 
by  repeating  the  dose  more  frequently  I  have  been  able  to  give  1\ 
grains  in  a  day.  Preparations  of  opium  have  the  advantage  of  not 
only  alleviating  pain  but  of  diminishing  intestinal  contractions  which 
are  the  cause  of  pain.  When  opium  does  not  agree,  the  hydrochlo- 
rate  of  morphia  may  be  tried  :  f  of  a  grain  may  be  dissolved  in  1^ 
ounce  of  water,  and  a  teaspoonful  given  every  hour  till  a  sedative  effect 
is  produced,  or  a  few  drops  of  a  stronger  solution  may  be  given 
subcutaneously. 

I  do  not  speak  of  anaesthetics,  as  the  effects  are  too  transitory  to  be 
of  much  use  except  in  those  cases  where  the  patient  cannot  tolerate 
opiates. 

As  for  superficial  transcurrent  cauterisation,  which  has  been  recom- 
mended to  alleviate  pain  after  inflammation  has  disappeared,  it  seems 
to  me  that  it  may  always  be  advantageously  replaced  by  one  of  the 
means  just  mentioned,  especially  by  subcutaneous  injections  of  morphia 
and  atropine. 

The  introduction  of  fragments  of  ice  into  the  vagina  have  also  been 
suggested ;  this,  however,  I  think  less  indicated  in  metritis  than  in 
metrorrhagia,  as  it  might  be  accompanied  by  a  dangerous  reaction. 


METRITIS  501 

For  vulval  pruritus^  starch  and  subnitrate  of  bismuth  should  be  used 
or  white  precipitate  of  mercury  (one  in  ten),  oxide  of  zinc,  borax,  alka- 
line lotions  or  Gowland^s  solution  (chlorohydrate  of  ammonia  and 
bichloride  of  mercury  aa  gr.  f,  emulsion  of  bitter  almonds  ^vij.  M.), 

Lastly,  we  must  favour  the  effects  which  we  are  entitled  to  expect 
from  this  treatment  by  hygienic  measures.  Occasions  of  catching 
cold  should  be  avoided,  especially  by  patients  suffering  from  endo- 
metritis, as  this  is  very  apt  to  be  succeeded  by  leucorrhoea  or  real 
uterine  catarrh;  they  should  wear  flannel  and  use  every  means  to 
restore  the  constitution. 

Treatment  of  chro7iic  metritis  and  its  complications. — The  treat- 
ment is  the  same  as  that  just  described,  only  in  cases  of  chronic  par- 
enchymatous metritis  and  especially  in  metritis  of  the  cervix,  it  is 
usually  advisable  to  commence  with  ignipuncture  of  the  cervix,  a  kind 
of  scarification  the  derivative  effect  of  which  may  be  advantageously 
followed  up  by  the  administration  of  alteratives,  alkaline  baths  and 
hydropathy. — This,  however,  is  insufficient  without  treating  the  leu- 
corrhoea, metrorrhagia,  fluxion,  congestion,  engorgement  and  hyper- 
trophy which  may  persist  after  the  cessation  of  pain  and  the 
inflammatory  symptoms  properly  so  called,  without  speaking  of  ovaritis, 
peri-uterine  inflammation,  and  other  complications  which  yield  less 
easily  than  metritis  itself. 

Metrorrhagia  when  acute  usually  yields  to  bleeding,  rest,  emollients, 
tepid  baths,  in  short  to  antiphlogistic  treatment.  When  chronic, 
whether  permanent  or  recurring  frequently,  or  at  intervals  of  three  or 
four  months  with  numerous  acute  phenomena,  of  which  I  have  seen 
cases,  it  ought  to  be  treated  at  first  by  tepid  injections  on  the  bidet 
or  in  a  general  bath,  and  even  by  very  hot  injections,  as  advised  by 
Emmet,  or  by  hot  applications  to  the  loins,  hypogastrium,  &c., 
according  to  Chapman^s  method  {see  p.  341).  But  in  the  chronic  form  of 
metritis  or  when  all  inflammation  appears  to  have  been  dissipated,  and 
when  hgemorrhage  is  the  only  persisting  result  of  it,  it  should,  on  the 
contrary,  be  treated  by  refrigeration  (cold  applications,  compresses, 
bladders  of  ice,  sulphuric  ether,  &c.,  to  the  abdomen ;  injections  and 
enemata  of  cold  water,  injections  on  the  bidet  with  ice-cold  water, 
vinegar,  alum,  &c.,  continuous  introduction  of  pieces  of  ice  into  the 
vagina,  or  cold  sitz-baths  of  running  water,  at  first  for  a  minute, 
but  gradually  prolonged  to  a  quarter  of  an  hour) ;  by  astringents 
(tincture  of  cinnamon  as  used  by  Becamier,  tannin,  rhatany,  alum, 
ergotine,  ergot  by  preference  when  the  tissue  is  soft,  perchloride  of 
iron  internally  as  well  as  in  injections) ;  by  cardiac  sedatives  (digi- 
taline,  or  the  infusion  of  the  leaves,  either  in  large  doses  as  recom- 
mended by  Howship,  Dickinson  and  Trousseau,  or  in  small  doses 
as  given  by  Gallard,  3^  to  7  gr.  of  leaves  infused  in  '^vf  of  water  and 
taken  in  the  day,  which  seems  to  me  sufficient ;  I  may  add  bromide 
of  potassium,  of  which  from  30  to  90  gr.  may  be  given  daily) ;  bv 
the  scraping  off  of  uterine  fungosities  with  Recamier's  curette ;  lastly, 
by  direct  cauterisation  of  the  uterine  mucous  membrane  [see  chapter 
on  Heemorrhage). 


502  UTEEINE    DISEASES    IN  DETAIL 

LeucorrJma,  ulcerations,  granulations,  fungosities  and  other  altera- 
tions of  the  mucous  membrane  necessitate  the  application  of  the  same 
topics  indicated  apropos  of  each  of  these  maladies. 

Chronic  congestion,  engorgement,  hypertrophy  of  the  uterine  tissue 
particularly  require  alteratives,  more  or  less  energetic  resolvents,  direct 
and  indirect,  external  and  internal,  employed  in  various  ways  during  a 
long  time,  or  frequently  resumed,  leaving  the  patient  intervals  of  rest. 

Energetic  resolvents,  alteratives  properly  so  called,  iodine  and  its 
preparations,  repeated  purgatives,  tonics  (iron  and  bark),  mineral 
waters  (sulphur,  iron,  or  alkaline  according  to  the  diathesis  of  the 
patient,  alkaline  especially  as  resolvent  of  engorgements,  such  as 
Vichy,  Eoyat,  Neris,  Carlsbad,  Ems)  ;  lastly  and  above  aU  if  there  is 
no  contra-indication,  hydropathy,  all  help  in  fulfilling  every  indication 
in  the  treatment  of  chronic  metritis.  Hydropathy  may  be  associated 
with  the  use  of  an  internal  medicament  or  some  mineral  water.  Eor 
instance,  I  often  prescribe  sulphur  water  internally  in  cases  of  chronic 
metritis  and  leucorrhcea  kept  up  by  a  catarrhal  or  rheumatic  condition 
simultaneously  with  the  cold  douche,  in  order  to  determine  a  good 
reaction.  When  parenchymatous  metritis  is  followed  by  a  state  of 
engorgement  or  hypertrophy,  alkaline  waters,  Yichy  especially,  are 
preferable. 

As  local  means,  in  cases  of  leucorrhceic  endometritis  especially, 
intra-uterine  injections,  astringent  or  caustic  applications  to  the 
uterus,  injections  of  tannin,  nitrate  of  silver  in  powder,  iodoform,  or 
the  actual  cautery  may  be  of  use  exceptionally.  I  shall  indicate  the 
manner  in  which  these  difi'erent  means  should  be  employed,  in  describ- 
ing the  special  treatment  of  endometritis. 

Lastly,  if  it  is  important  to  superintend  the  convalescence  of  acute 
metritis  in  order  to  avoid  relapses  or  the  transition  from  the  acute  to 
the  chronic  stage,  it  is  of  equal  consequence  to  watch  over  the  cure  of 
chronic  metritis,  especially  at  the  monthly  period,  to  avoid  the  conse- 
quences of  an  abnormal  fluxionary  movement  and  the  persistent  con- 
gestion of  the  organ,  if  not  the  recurrence  of  metritis.  Although  we 
do  not  admit  the  incurability  of  chronic  metritis,  like  Scanzoni,  we 
acknowledge  that  after  some  amelioration  of  the  local  disease  and 
general  state  the  slightest  cause  suffices  to  produce  a  relapse. 
We  must  also  use  every  effort  to  remove  all  traces  of  leucorrhoea, 
congestion  or  engorgement,  consequences  of  metritis  which  tend  to 
be  perpetuated  and  to  bring  back  the  metritis  itself,  by  continuing 
for  a  long  time  the  cold  irrigations,  the  resolvent  frictions,  the  pur- 
gatives, and  especially  hydropathy ;  taking  two  courses  of  mineral 
waters  when  indicated ;  above  all  keeping  up  the  strength  by  tonics, 
restoring  the  constitution  by  iron  and  by  a  generous  diet,  and  remem- 
bering that,  like  the  fluxion  and  congestion  which  are  their  constitu- 
tive elements,  chronic  phlegmasias  are  perpetuated  and  have  a  con- 
tinual tendency  to  be  reproduced  in  the  affected  organs  in  delicate 
patients.  The  only  means  of  facilitating  their  displacement,  of  hast- 
ening their  disappearance  and  preventing  their  return  is  to  give 
sufficient  strength  to  the  patient  to  maintain  this  state  of  equilibrium. 


METRITIS  503 

Treatment  of  the  various  hinds  of  Metritis.  1.  Puerperal  me- 
tritis.— This  is  often  fatal  by  its  natural  consequences  and  by  its 
complications.  However  rapid  its  evolution  may  be,  in  this  kind 
as  in  others,  the  inflammation  may  have  its  seat  more  especially  in 
one  or  other  of  the  histological  zones,  mucous  membrane,  muscular 
or  cellular  tissue,  and  merit  the  names  of  endometritis,  idiometritis, 
exometritis,  given  by  Hervieux.  Endometritis  is  characterised  in  the 
first  stage  by  hypersemia,  redness,  thickening  of  the  mucous  mem- 
brane especially  on  a  level  with  the  placenta,  by  the  viscous, 
reddish  thick  coating  which  covers  this  membrane,  by  the  projec- 
tion of  its  utricular  glands,  softening,  epithelial  denudation,  exul- 
cerations,  sometimes  by  clots  and  even  fibrinous  concretions  closing 
a  gaping  vascular  os.  In  the  second  stage  which  is  very  common 
being  the  termination  by  suppuration,  the  uterine  cavity  is  lined 
by  a  fluid  sometimes  reddish  brown,  sometimes  yellow  and  puru- 
lent, of  thick  consistency  especially  on  a  level  with  the  placental  disc, 
of  a  strong  smell,  infiltrated  into  the  very  tissue  of  the  softened 
mucous  membrane,  and  even  into  the  vessels  which  are  more  or 
less  occluded  by  sanguineous  clots  or  puriform  concretions.  A 
very  serious  complication  of  suppurative  endometritis  is  diphtheria 
and  the  most  serious  termination  is  mortification,  either  from 
putrid  softening  or  necrobiosis,  or  from  gangrene  properly  so 
called. 

Idiometritis,  by  the  admission  of  Hervieux,  is  rarely  met  with 
unaccompanied  by  endometritis.  When  the  inflammation,  passing  the 
limits  of  the  mucous  membrane,  has  invaded  the  muscular  tissue  of 
the  uterus,  the  latter  organ  remains  large,  tumefied,  red  and  soft.  If 
the  inflammation  pursues  its  course  it  may  terminate  by  suppuration 
and  even  by  gangrene.  Usually,  it  is  in  the  sinuses  and  in  the  veins 
that  pus  is  found,  but  the  muscular  tissue  itself  may  be  invaded  by 
suppuration  which  comes  from  the  veins  or  from  the  mucous  mem- 
brane. The  pus,  infiltrated  at  first  between  the  bundles  of  muscular 
fibres,  at  last  collects  and  forms  real  abscesses. 

Puerperal  exometritis  seems  to  me  more  frequently  connected  with 
a  phlegmon  of  the  broad  ligaments,  of  which  it  is  frequently  the 
starting  point,  than  with  other  anatomical  forms  of  puerperal  metritis  ; 
nevertheless,  it  cannot  be  denied  that  inflammation  is  in  certain  cases 
more  or  less  limited  to  the  cellular  tissue  forming  the  immediate  enve- 
lope of  the  uterus  or  of  the  veins,  or  oftener  still  the  lymphatic  net- 
work contained  in  it.  Hervieux  says  :  "  The  possible  complications 
of  puerperal  metritis  are  so  numerous,  that  in  order  to  indicate  them 
all  the  cadaveric  alterations  to  which  puerperal  poisoning  may  give 
rise  must  be  enumerated.  Phlebitis,  and  especially  uterine  phlebitis, 
general  or  partial  peritonitis,  phlegmon  of  the  broad  ligament,  salpin- 
gitis, ovaritis  are  its  usual  concomitants ;  then  pulmonary  conges- 
tion should  be  mentioned,  the  visceral  purulent  diathesis,  the  peri- 
pheric purulent  diathesis,  fatty  degeneration  of  the  liver,  hyperplasia 
tumefaction  of  the  spleen,  parenchymatous  inflammation  of  the 
kidneys,  all  lesions  denoting   a   state  of  general  intoxication  of  the 


504  UTERINE   DISEASES    IN   DETAIL 

organism"    (Traiie   cliniqiie   et    pratique  des  maladies  piier per  ales  ^ 
p.  259). 

According  to  the  intensity,  acuteness  and  degree  of  complication  of 
the  malady,  puerperal  metritis  may  run  through  all  its  phases  in  two 
or  three  days  ending  fatally  very  quickly ;  or  its  duration  may  be 
prolonged  to  the  point  of  producing  suppuration  and  allowing  the 
effects  of  art  and  nature  to  triumph  in  some  cases  over  the  complica- 
tions (diphtheria,  gangrene,  lymphangitis,  phlebitis,  peritonitis),  how- 
ever redoubtable  they  be  ;  or  lastly,  it  may  remain  in  a  state  of  rela- 
tive simplicity  which  allows  of  the  hope  of  resolution  in  ten  days, 
except  in  cases  where  the  cellular  peri-uterine  tissue  or  one  of  the 
broad  ligaments  participates  in  the  inflammation  and  recovery  is 
necessarily  slower.  The  best  preventive  means  are :  proper  care  at 
delivery ;  avoiding  contusions,  lacerations  of  the  neck,  tractions  on  the 
cord ;  taking  care  to  leave  no  fragments  of  the  placenta  in  the  uterus ; 
arresting  haemorrhage  by  the  administration  of  ergot  continued  long 
enough  to  favour  the  contraction  of  the  uterus  as  much  as  possible. 
Treatment  consists  at  first  in  the  application  of  leeches  or  cupping 
glasses,  repeated  when  necessary,  at  the  seat  of  pain,  followed  by  the 
administration  of  ipecacuanha  in  a  dose  sufficient  to  produce  vomiting, 
of  emollient  and  sedative  cataplasms  covered  by  oil  silk,  and  large 
bKsters,  as  well  as  leeches  or  cupping  glasses  applied  to  the  hypogas- 
trium;  a  thick  layer  of  mercurial  and  belladonna  ointment  (Ung. 
Hydrarg.  5  iij,  Ext.  Bellad.  gr.  Ixxv  to  cl)  may  also  be  applied  to  the 
abdomen,  covered  with  oil  silk  and  left  for  several  days  (taking  care  to 
avoid  salivation  by  frequently  gargling  with  a  solution  of  chlorate  of 
potash,  and  by  great  attention  to  the  cleanliness  of  the  mouth,  for 
notwithstanding  the  contrary  opinion  of  many  physicians  of  high 
standing,  among  others  of  Hervieux,  op.  cit.,  p.  270,  I  cannot  believe 
in  any  good  effect  being  produced  by  mercurial  salivation).  Mild  pur- 
gatives should  also  be  given,  not  only  to  prevent  constipation  but  also 
to  produce  a  revulsive  and  eliminating  action ;  which  need  not  prevent 
the  strength  being  kept  up  in  the  interval  by  a  diet  appropriate  to  the 
state  of  the  patient,  wine  and  brandy  being  given  in  small  doses 
frequently  repeated ;  bark  and  quinine  may  also  be  resorted  to  when 
the  phenomena  of  suppuration  and  puralent  infection  seem  to  in- 
dicate it.  Digitalis  and  aconite  may  also  be  used  to  moderate  the 
fever.  But  above  all  excessive  cleanliness  must  be  kept  up  in  the 
vagina  and  uterine  cavity,  and  the  surface  of  the  latter  should  be 
modified  by  vaginal  and  intra-uterine  detersive  injections,  too  often 
even  now  neglected  by  practitioners.  Anxious  as  I  am  to  warn  my 
young  confreres  of  the  dangers  of  these  injections  into  a  uterus  in  a 
state  of  vacuity  with  a  narrow  os  {see  Leucorrhoea),  I  am  equally 
desirous  of  persuading  them  to  have  recourse  to  them  as  one  of  the 
most  valuable  means  at  our  command  in  cases  of  puerperal  metritis. 
I  may  take  this  opportunity  of  adding  the  results  ^  of  my  experience  to 
those  of  Hervieux,  of  Pontaine  his  Eesident  [Etudes  stir  les  injec- 
tions uterines  apres  I' accouchement,  theses  de  Paris,  1869),  and  of 
others  in  contributing  to  introduce  into   practice  a  means  which,^ 


METRITIS  505 

although  presenting  some  danger,  is  often  the  most  powerful  and 
perhaps  the  only  one  which  we  possess  to  prevent  the  terrible  conse- 
quences of  puerperal  metritis,  whether  suppurative,  diphtheritic  or 
gangrenous.  Therefore  whenever  a  purulent  ichorous  fluid  more  or 
less  foetid  is  discharged  from  the  uterus  we  must  not  hesitate  to  have 
recourse  to  intra-uterine  injections  simultaneously  with  the  other 
means  of  treatment  already  enumerated.  An  ordinary  gutta-percha 
male  catheter  of  medium  size  is  sufficientj  for  the  cervix  is  widely  open 
at  this  time  and  the  fluid  injected  into  the  uterus  comes  back  again  too 
easily  to  admit  any  danger  of  its  flowing  towards  the  Pallopian  tubes. 
The  patient  lies  on  her  back  on  the  edge  of  the  bed,  or  better  still  on 
the  side  (the  English  position)  ;  the  index  finger  of  one  hand  is  placed 
on  the  cervix  whilst  the  extremity  of  the  catheter  is  placed  against 
this  finger  with  the  other  hand,  and  is  easily  insinuated  into  the 
uterus ;  the  canula  of  a  syringe,  irrigator  or  hydroclyse  is  fitted  into 
the  catheter ;  and  after  making  sure  that  no  air  has  been  admitted, 
we  gently  and  slowly  inject  from  half  a  pint  to  two  pints  of  a  tepid 
detersive  fluid,  which  is  received  into  a  basin  as  it  returns  from  the 
vulva.  As  soon  as  the  water  when  expelled  is  free  from  all  patholo- 
gical elements,  we  can  cease  the  injection.  One  or  two  intra-uterine 
injections  may  be  made  daily  in  addition  to  the  vaginal  lotions  and 
injections  which  ought  to  be  much  more  frequently  repeated.  The 
best  are  :  chlorinated  water  (Sod.  Hypochlorit.  gr.  xv,  Infus.  Chamom. 
3j),  aromatic  infusions,  or  water  to  which  has  been  added  a  little  coal 
tar  or  a  few  drops  of  carbolic  acid,  permanganate  of  potassium,  tinc- 
ture of  iodine,  salicylate  of  soda,  &c. 

II.  Post-puerperal  metritis. — It  usually  affects  the  whole  of  the 
uterus.  It  is  generally  due  to  the  imprudence  of  the  patient,  to  her 
having  risen  too  soon,  or  to  her  having  resumed  marital  intercoarse 
too  early  after  delivery,  or  to  a  return  of  uterine  fluxion,  a  tardy 
haemorrhage,  &c.  Unless  it  be  developed  subsequent  to  a  late  phle- 
bitis of  the  uterine  tissue  owing  to  the  formation  of  a  clot  in  a  sinus, 
it  never  has  the  gravity  of  puerperal  metritis,  for  it  neither  has  its 
acute  character  nor  its  suppurative  nor  gangrenous  terminations,  nor 
its  numerous  and  terrible  complications.  But  it  often  becomes  the 
starting-point  of  a  chronic  metritis  all  the  more  lasting  from  the 
organ  affected  being  much  larger  than  in  a  state  of  vacuity  and  in  a 
condition  of  congestion  and  nutritive  activity  unfavorable  to  the  reso- 
lution of  the  phlegmasia.  Thus  it  often  commences  by  assuming  the 
subacute  form,  it  is  perpetuated  indefinitely  in  the  chronic  form,  and 
even  when  it  is  extinct  it  may  be  the  starting  point  of  an  almost 
irremediable  alteration,  the  persistence  of  an  abnormality  in  the 
size  and  structure  of  the  organ.  It  is  then  troublesome  from  this 
double  point  of  view :  that  it  is  frequently  the  starting-point  of 
chronic  metritis,  and  that  it  often  becomes,  even  when  dissipated  by 
suitable  treatment,  a  cause  of  arrest  of  the  retrograde  evolution  of 
the  uterus.  On  these  accounts  post-puerperal  metritis  requires  prompt 
and  energetic  treatment.  Leeches  may  be  indicated ;  hot  cata- 
plasms night  and  day;    daily  tepid   baths,  emollients  and  later  on 


506  UTEEINB    DISEASES   IN   DETAIL 

alkaline  baths  with  injections,  mercurial  and  belladonna  ointment 
on  the  belly,  blisters,  repeated  purgatives,  later  on  resolvents,  ergot, 
and  lastly,  general  revulsive  frictions,  tonics,  electricity,  and  hydro- 
pathy during  convalescence  constitute  the  most  efficient  means  of 
treatment. 

III.  Partial  metritis  of  the  hody  of  the  uterus. — It  frequently 
follows  post- puerperal  metritis  or  neglected  abortion,  but  is  more  fre- 
quently a  consequence  of  dysmenorrhoea,  either  in  virgins  or  in  newly- 
married  women,  owing  to  increased  menstruation  excited  by  coitus.  It 
may  be  acute,  but  generally  it  follows  a  chronic  course.  The  subjec- 
tive symptoms  are :  pain,  invariably  hypogastric,  frequently  left  iliac, 
sometimes  right  iliac,  very  rarely  lumbar;  discomfort  and  weight  in 
the  pelvis ;  pain  referred  to  the  sacro-iliac  articulations,  the  groins 
and  thighs ;  most  frequently  dyspepsia,  nausea,  chloro-ansemia,  with 
general  symptoms  analogous  to  those  of  pregnancy  and  dependent 
on  reflex  action  provoked  by  abnormal  vital  activity  of  the  body  of 
the  uterus.  The  malady  is  easily  diagnosed  by  associating  touch  with 
palpation. 

Treatment. — Leeches  or  cupping  glasses  to  the  hypogastrium,  groins 
or  vulva,  repeated  when  necessary  and  followed  the  next  day  by  a  pur- 
gative ;  general  baths,  prolonged  horizontal  decubitus ;  the  continuous 
application  of  mercurial  and  belladonna  ointment ;  daily  laxatives ; 
later  on  alkaline  waters,  resolvents,  alteratives  and  tonics,  according 
to  the  constitution  and  temperament  of  the  patient  or  the  diathesis 
which  may  help  to  keep  up  the  disease ;  afterwards  ergot,  general 
cutaneous  frictions  and  hydropathy. 

IV.  Partial  metritis  of  the  cervix. — It  frequently  follows  lacerations 
of  the  cervix  during  delivery,  various  traumatisms  to  which  this  organ 
is  subject,  excessive  coitus,  &c.  The  subjective  symptoms  are :  con- 
stant Irmbar  pain,  left  or  right  iliac  and  hypogastric  pain  rarely; 
pelvic  discomfort  communicated  to  the  anus,  rectum  and  bladder, 
sometimes  c-^en  to  the  stomach  and  nervous  system,  but  more  rarely 
than  in  met;ritis  of  the  body.  Occasionally  enormous  tumefaction  of 
the  cervix  ^ith  heat  and  pain ;  frequently  alteration  in  its  form  with 
sometimes  softening  of  its  tissue,  sometimes  induration,  according 
to  the  period  of  the  inflammation  ;  often  cervical  leucorrhoea,  ulcera- 
tions, granulations,  fungosities,  epithelial  or  mucous  polypi,  the  last 
consequences  of  this  inflammation. 

Treatment. — Scarifications  more  or  less  deep  and  numerous,  or 
leeches  to  the  cervix  followed  by  purgatives,  prolonged  emollient  baths 
with  vaginal  injections  and  even  continued  tepid  irrigations  in  bed,  or 
injections  for  a  quarter  of  an  hour  and  repeated  every  hour,  with  decoc- 
tions or  emollient,  sedative,  narcotic  solutions  (marshmallow,  starch, 
henbane,  belladonna,  poppies,  hemlock,  bromide  of  potassium)  ;  laxa- 
tives ;  afterwards,  resolvent  applications  to  the  cervix  with  tampons 
saturated  in  glycerine  or  covered  with  mercurial  and  belladonna 
ointment,  iodide  of  lead  or  red  oxide  of  mercury;  application 
to  the  cervix  of  calomel,  tincture  of  iodine,  iodoform  ;  alkaline  baths 
with  injections;  later  on,  astringent  injections  and  even  the  actual 


METRITIS  507 

cautery  simultaneously  with  alkaline  waters,  iodide  of  iron,  effervescing 
iron  waters,  bark,  cold  injections,  hydropathy. 

Y.  Endometritis. — It  is  sometimes  acute,  sometimes  chronic ;  even 
under  this  latter  form  it  may  not  go  much  beyond  the  elements  of  the 
mucous  membrane  or  submucous  tissue,  not  reaching  the  muscular 
tissue,  or  at  least  not  reaching  it  sufficiently  to  give  rise  to  other  in- 
dications than  those  which  naturally  proceed  from  inflammation  of  the 
mucous  membrane,  leucorrhoea,  ulcerations,  granulations,  fungosities, 
&c. — Metrorrhagia  is  frequently  a  symptom,  but  not  so  pathogno- 
monic as  Gallard  says,  for  it  may  occur  after  simple  fluxion,  or  a 
congestive  state  of  the  mucous  membrane,  as  well  as  after  an  acute 
inflammatory  condition  of  this  membrane;  it  depends  also  some- 
times on  a  softening  which  has  nothing  inflammatory  and  often  on 
bleeding  fungosities  developed  in  the  body,  analogous  to  those  ob- 
served so  frequently  on  the  cervix  causing  a  flow  of  blood  on  the  least 
fluxionary  movement.  Owing  to  the  existence  of  these  fungosities  and  to 
the  accompanying  hypertrophy  or  simple  swelling  of  all  the  mucous 
membrane,  this  fluxionary  movement  is  followed  by  a  persistent  con- 
gestion and  by  a  hsemorrhage  sometimes  very  persistent  and  very 
abundant,  recurring  every  month  and  even  oftener,  and  lasting  some- 
times uninterruptedly  from  one  period  to  another,  weakening  patients 
greatly;  but  these  fungosities  themselves  are  not  necessary  conse- 
quences of  inflammation ;  like  polypi  they  may  be  developed  inde- 
pendently of  it,  and  strictly  speaking  without  the  intervention  of  endo- 
metritis; admitting  that  endometritis  is  their  starting-point,  they  are 
only  developed  as  an  effect  of  the  modifications  which  inflammation  has 
produced  on  the  mucous  membrane,  in  consequence  of  its  softening  and 
hypertrophy,  and  therefore  they  are  much  more  characteristic  of  the 
chronic  than  of  the  acute  form  of  endometritis,  and  consequently  the 
haemorrhages  to  which  they  give  rise  are  symptoms  of  chronic  as  well 
as  of  acute  endometritis ;  lastly,  I  repeat  that  metrorrhagia  in  itself  has 
no  pathognomonic  signification,  for  it  may  be  the  consequence  of  non- 
inSammatory  fungosities,  or  of  the  fluxion,  congestion  and  softening  just 
referred  to,  or  it  may  be  produced  simply  by  the  existence  of  an  intersti- 
tial fibroma  or  intra-uterine  polypus  or  cancer,  not  to  speak  of  the  general 
alterations  of  blood  which  may  cause  hsemorrhage  from  the  uterus  as  from 
other  organs. — Leucorrhoea  is  a  more  characteristic  symptom  of  endo- 
metritis than  metrorrhagia ;  it  coincides  with  the  latter  or  alternates  with 
it,  or  it  is  manifested  alone ;  it  may  be  simply  mucous  or  more  or  less 
purulent,  limited  to  the  uterus  and  even  to  one  of  its  segments  (body 
or  neck),  or  be  extended  to  the  vagina,  sometimes  accompanied  by 
erosions  and  various  eruptions  on  the  uterus,  vagina  and  vulva,  by 
vulval  pruritus  and  even  by  cutaneous  eruptions. — There  are  also 
heat,  enlargement  of  the  os  internum  (unless  polypoid  fungosities  or 
swelling  of  the  mucous  membrane  obstruct  it  in  part),  marked  pain, 
sometimes  very  acute,  ehcited  by  the  sound,  and  a  tendency  to  bleeding 
after  this  little  operation. 

Treatment. — Leeches  to  the  cervix,  superficial  scarifications  of  the 
vaginal  portion  or  of  the  intra-cervical  mucous  membrane,  purgatives. 


508  UTEEINE   DISEASES    IN    DETAIL 

cutaneous  revulsives  to  the  abdomen  (blisters,  iodine,  &c.),  per- 
chloride  of  iron,  digitalis,  later  on  ergot  (especially  if  the  organ  is 
soft)  to  subdue  the  hsemorrhage,  as  well  as  refrigerants,  ice  and  (in 
the  chronic  period)  even  scraping  with  Recamier's  curette,  cauterisa- 
tion with  nitrate  of  silver,  and  intra-uterine  injections  with  tincture  of 
iodine,  solution  of  nitrate  of  silver,  &c.^  (A.  Guichard,  Recherches 
sur  les  injections  intra-uterines  en  dehors  de  I'etat  puerperal.  These 
de  Paris,  1870.  Dupierris,  De  I'effieacite  des  injections  iodees  de  la 
cavite  de  ruterus.  Paris,  1870).  I  have  described  how  these  injec- 
tions should  be  made  in  the  puerperal  state,  and  shall  here  merely 
refer  to  the  precautions  to  be  taken  in  making  them  when  the  uterus 
is  in  a  state  of  vacuity.  Above  all  the  orijices  should  be  sufficiently 
large  or  dilated  so  that  the  fluid  can  easily  return  however  small  be 
the  quantity  injected,  and  the  contractions  produced  by  its  presence  in 
the  womb  can  easily  expel  it.  In  addition,  the  acute  injiammatory 
symptoms  should  have  been  previously  siibdued.  "We  may  then  use  a 
metallic  or  gutta-percha  catheter  (the  latter  is  often  insufficient  on 
account  of  its  softness)  of  calibre  equal  to  the  ordinary  sound,  and  by 
means  of  a  small  syringe  a  quantity  of  fluid  in  proportion  to  the 
capacity  of  the  uterine  cavity  may  be  injected  very  gently ;  usually  a 
few  drops  is  sufficient  to  reach  the  whole  mucous  membrane.  I  am 
accustomed  to  administer  previously  a  small  sedative  enema  with 
fifteen  drops  of  laudanum,  in  order  to  diminish  the  pain  of  the  uterine 
colics  which  the  presence  of  fluid  in  the  cavity  of  the  womb  does  not 
fail  to  produce,  and  shortly  afterwards  I  prescribe  a  prolonged  emol- 
lient bath  with  vaginal  injection,  emollient  cataplasms  on  the 
abdomen,  and  rest  in  bed.  Later  on,  we  may  prescribe  daily  astrin- 
gent vaginal  injections.  In  this  chronic  period  of  the  malady  we 
must  also  consider  the  general  phenomena  and  diathetic  conditions 
which  follow,  complicate  or  keep  up  the  endometritis  :  dyspepsia, 
chloro-ansemia  and  herpetism  must  especially  be  treated.  With  this 
object  we  have  recourse  to  pepsine,  alkaline  drinks,  laxatives,  iron 
preparations  associated  with  tonics  (rhubarb,  bark,  quassia),  sedatives 
(one  or  two  drops  of  laudanum  or  of  a  solution  of  gr.  1 1  of  morphia 
in  Tillxxv  of  cherry  laurel  water  (Gallard)  or  gr.  \  of  powdered  bella- 
donna root  before  food),  stimulants  (bark,  wine,  absinthe,  cinnamon, 
pepper,  cofi'ee,  before  or  after  meals),  arsenical  preparations,  balsams, 
(tar-water,  tolu,  &c.),  sulphur  waters  and  hydropathy. 

YI.  Parenchymatous  metritis. — It  may  also  be  acute  or  chronic, 
but  of  all  the  forms  it  is  the  one  which  persists  the  longest,  and  which 
is  met  with  most  frequently  in  the  chronic  state.  There  are,  accord- 
ing to  the  period  or  the  individual  tendencies,  softening  or  induration 
of  the  tissue  simultaneously  with  increased  size  of  the  organ,  amenor- 
rhcea,  or  diminution  of  menstruation,  especially  at  the  period  of  indu- 

>  AtHll  {The  Duhlin  Journal  of  Medical  Science,  Jan.,  1873)  cauterises  the 
mucous  membrane  with  nitric  acid  by  means  of  the  intra-uterine  speculum  in 
cases  where  other  means  have  failed.  According  to  Blanchard  {De  la  cauterisa- 
tion de  la  cavite  uterine  dans  la  metrite  chronique.  Theses  de  Paris,  1873) 
Laroyenne  of  Lyons  obtains  good  results  fi-om  this  cauterisation,  which  proves 
the  innocuity  of  nitrate  of  silver  in  these  cases. 


METRITIS  609 

ration,  sometimes  also  dysmenorrhoea.  The  uterine  cavity  is  sensibly 
increased,  and  the  orifices,  especially  the  internal,  are  almost  always 
enlarged  by  excentric  dilatation  of  the  walls.  Hypogastric,  lumbar, 
inguinal  and  pelvic  pain  are  present  with  a  feeling  of  fulness  and 
weight  increasing  often  considerably  at  the  monthly  period  and  per- 
sisting afterwards.  To  these  are  added  dyspepsia,  chloro -anaemia, 
debility  and  frequently  emaciation  and  serious  alteration  of  the  health, 
especially  when  the  disease  is  of  long  standing. 

Treatment. — Leeches  and  deep  and  repeated  scarifications  of  the 
cervix  followed  by  prolonged  alkaline  and  emollient  baths  with  injec- 
tions ;  and  purgatives  replaced  afterwards  by  daily  laxatives,  emollient 
cataplasms,  mercurial  ointment  applied  to  the  abdomen  and  injected 
per  rectum.  Later  on,  cauterisation  of  the  cervix,  several  punctures 
of  from  5  to  10  millimetres  being  made  with  a  fine  point  at  red 
heat  so  that  a  resolvent  and  derivative  action  may  be  exercised  at 
several  points.  Simultaneously  and  afterwards,  tonics,  solvents, 
mineral  waters  and  hydropathy. 

The  manner  in  which  I  associate  these  various  methods  is  the  fol- 
lowing :  I  apply  leeches  to  the  cervix  or  practise  scarification,  once  or 
twice  after  menstruation  if  pain  is  increased  at  that  time,  administer- 
ing an  emollient  bath  the  next  day  and  a  purgative  the  day  following  j 
I  prescribe  three  alkaline  baths  (Sod.  Bicarb,  ^vij  and  2  lbs.  of  bran)  a 
week,  with  vaginal  injection  during  the  bath  and  rest  in  bed  for  an 
hour  afterwards ;  every  morning  friction  of  the  whole  body  with 
flannel  saturated  with  a  solution  of  ammoniated  camphor  or  the 
tincture  of  some  aromatic  tonic  (bark,  benzoin,  &c.)  j  ten  minutes 
before  each  meal  to  take  from  a  quarter  to  a  whole  glass  of  Vichy, 
Andabre,  Boulou,  or  Vals  mineral  water  or  an  artificial  alkaline  water 
(75  grains  of  bicarbonate  of  soda  to  the  quart),  at  the  commencement 
of  every  meal  some  iron  preparation  (iodide  of  iron),  and  during  the 
meal  an  effervescing  iron  mineral  water  (Bussang,  Orezza,  Lamalou, 
Vals,  &c.) ;  and  a  tablespoonful  morning  and  evening  of  the  following 
prescription  :  B:  Pot.  lod.  ^j,  Aquse  ^^j,  increasing  the  dose  of  iodide 
30  grains  every  week  till  30  or  45  grains  are  taken  every  day ;  if  the 
patient  cannot  take  this  preparation  I  substitute  the  chloride  of  gold 
and  sodium  (gr.  -^-^  to  gr.  %  a  day)  or  an  arsenical  preparation  if 
nutrition  requires  to  be  stimulated,  the  patient  being  thin  and  pale  or 
presenting  symptoms  of  herpetism ;  or  bromide  of  potassium  or 
sodium  if  she  is  nervous  or  hysterical ;  the  application  of  some  resol- 
vent ointment  (mercury  or  the  iodide  of  lead  and  potassium)  to  the 
hypogastrium  and  groins,  or  as  an  injection  into  the  rectum  and  even 
into  the  vagina ;  an  india-rubber  abdominal  belt  to  keep  up  a  con- 
stant moisture  round  the  pelvis  and  to  retain  the  cataplasms  in  place 
at  the  menstrual  period  or  when  pain  is  increased ;  lastly,  to  terminate 
the  treatment  by  hydropathy  (general,  never  local,  exceptionally  sitz- 
baths  of  running  water),  alternating  or  associated  with  mineral  waters, 
either  sulphurous,  such  as  Vernet,  Luchon,  Aix,  or  saline,  such  as 
Royat,  Plombieres,  la  Bourboule ;  or  alkaline,  such  as  Vichy,  Anda- 
bres,    Sylvanes ;    thus,    I   often   prescribe   the  association  of  Vichy 


510  UTERINE    DISEASES   IN   DETAIL 

waters  internally  and  in  baths  (with  injections)  in  the  morning,  and 
general  hydropathy  in  the  afternoon,  and  I  have  seen  the  good  effects 
produced  by  these  means  in  terminating  a  treatment  successfully 
begun.  It  is  especially  in  cases  of  venous  congestive  metritis^  which 
is  so  difficult  to  cure,  that  courses  of  hydropathy,  repeated  twice  a 
year  and  associated  with  the  use  of  alteratives,  exercise  and  good 
hygiene  are  indispensable  in  restoring  patients  to  health. 


Ovaritis  and  Salpingitis. 

1.   Ovarian  Inflammation. 

Ovaritis  or  oophoritis  is  inflammation  of  the  ovary.  There  are  not 
only  differences  of  degree  but  differences  of  nature  between  this 
inflammation  and  catamenial  fluxion.  Tilt^  seems  to  have  ignored 
this  fact  in  creating  the  term  subacute  ovaritis,  divided  into  amenor- 
rhceic,  dysmenorrhoeic,  and  menorrhagic ;  it  seems  to  me  to  be  rather 
an  irregularity  of  the  ovarian  catamenial  fluxion,  or  a  chronic  ovaritis, 
producing  menstrual  disorders  which  may  affect  the  three  principal 
forms  which  we  have  specially  described.  Aran  ^  on  the  other  hand 
has  exaggerated  the  difficulty  there  is  in  separating  physiological  or 
slightly  disordered  ovulation  from  ovaritis.  The  ovarian  functions 
being  the  most  important  amongst  those  of  the  genital  organs,  all  the 
others  being  in  a  measure  subordinate  to  them,  it  is  not  surprising 
that  diseases  of  the  ovaries,  and  especially  their  inflammation,  should 
react  still  more  than  those  of  the  uterus,  and  sometimes  in  the  most 
troublesome  way,  not  only  on  the  genital  economy  but  on  the  whole 
organism.  With  the  ovaries,  as  with  the  uterus,  morbid  states  without 
neoplasms  are  not  limited  to  inflammation.  Pluxion,  congestion,  en- 
gorgement, hypertrophy,  neuralgia  seem  to  me  as  much  entitled  to 
have  a  place  here  as  acute  and  chronic  inflammation.  Nevertheless  I 
have  not  thought  it  necessary  to  multiply  descriptions  and  devote  a 
chapter  to  every  distinct  morbid  condition.  I  have  abstained  from 
doing  so  for  two  reasons  :  the  first  is  that  some  of  these  morbid  con- 
ditions, such  as  fluxion  and  congestion,  are  recognised  by  signs  analo- 
gous to  those  of  uterine  fluxion  and  congestion  and  require  almost  the 
same  treatment ;  the  second  is  that  the  others,  such  as  engorgement, 
hypertrophy,  neuralgia,  cannot  always  be  distinguished  from  maladies 
of  the  neighbouring  organs.  I  shall  content  myself,  therefore, 
apropos  of  the  differential  diagnosis  of  ovaritis,  with  giving  a  brief 
sketch  of  these  various  morbid  states  and  of  the  treatment  required. 

Pathological  Anatomy. — According  to  Boivin  and  Duges^  and 
Chereau,*  the  anatomical  alterations  of  ovaritis  may  be  connected  with 

1  On  Uterine  and  Ovarian  Inflammation,  p.  294.  London,  1862. 

2  Op.  cit.,  p.  572. 

'  Op.  cit.,  t.  ii,  p.  564. 

4  Memoire  pour  servir  a  V etude  des  maladies  des  ovaires.  Pans,  1844. 


OVARITIS    AKD    SALPINGITIS  511 

four  principal  stages :  hypersemia,  tumefaction  and  softening,  suppu- 
ration, grey  softening  and  putrilaginous  or  gangrenous  decay.  To 
these  must  be  added  induration,  which  Chereau  rightly  describes  as 
characteristic  of  chronic  ovaritis,  and  which  is  always  accompanied,  in 
this  disease,  by  alterations  of  another  kind. 

Before  describing  the  anatomical  characters  of  these  alterations,  the 
periods  of  the  malady  to  which  they  are  related,  and,  as  far  as  possible, 
the  symptoms  leading  us  to  suspect  them,  I  copy  Scanzoni^s  ^  excel- 
lent description  of  an  inflamed  ovary  met  with  accidentally  in  a  woman 
suffering  from  pneumonia.  "  The  autopsy  showed,  in  the  pelvis,  to 
the  right  of  the  uterus,  a  coagulated  mass  of  fibrin  of  the  size  of  the 
fist,  easily  separated  from  the  adjacent  organs,  and  which  evidently 
resulted  from  an  effusion.  After  its  removal  the  bvary  was  seen  pre- 
senting a  longitudinal  diameter  of  2$  inches,  whilst  the  transverse  dia- 
meter was  1 J  inch,  and  the  thickness  of  the  organ  about  1|  inch.  The 
ovary  had  an  ovoid  form,  it  was  considerably  enlarged,  its  surface  was 
deep-blue  and  covered  with  numerous  dilated  veins,  and  towards  the 
internal  angle  of  the  posterior  surface  the  place  of  an  ovarian  vesicle 
which  had  burst  a  short  time  previously  was  recognised  by  its  dark- 
red  colour.  The  consistency  of  the  organ  was  pasty,  almost  fluctuat- 
ing at  some  points.  In  cutting  it  a  considerable  mass  of  blood  flowed 
and  the  section  showed  the  same  violet  colour  and  some  venous  vessels 
greatly  engorged.  The  vesicle  in  question  on  which  the  point  of 
rupture  was  easily  seen  was  the  size  of  a  pea;  it  contained  in  its 
centre  a  little  black  liquid  blood,  whilst  the  walls  were  covered  by  a 
thick  layer  of  fibrin.  Two  neighbouring  vesicles  presented  almost  the 
same  dimensions,  projecting  slightly  above  the  surface  of  the  ovary ; 
on  opening  them  a  serous  sanguineous  fluid  was  discharged.  Towards 
the  other  extremity  of  the  organ,  where  the  congestion  was  less  strong, 
the  red  less  intense,  and  the  consistency  ^firmer,  there  was  in  the 
parenchyma  an  abscess  of  the  size  of  a  bean  containing  sanious  pus 
mixed  with  blood.  Beside  this  rather  large  abscess  there  were  other 
smaller  ones,  the  size  of  which  varied  from  that  of  a  millet  seed  to  a 
pea,  all  situated  deeply  in  the  parenchyma  and  all  containing  sanious 
pus.  The  whole  tissue  was  infiltrated  with  serosity,  and  the  majority 
of  the  vesicles  were  visibly  enlarged  by  an  abundant  accumulation  of 
fluid.  The  pathological  alterations  observed  in  this  ovary  correspond 
exactly  with  the  description  of  acute  ovaritis  given  by  some  writers ; 
considerable  increase  in  the  size  of  the  organ,  marked  hypersemia, 
traces  of  efiusion  into  the  vesicles,  purulent  centres  in  the  parenchyma 
and  fibrinous  exudation  on  the  peritoneal  covering  of  the  organ." 

Gallard^  remarks  that  this  description  represents  a  type  of  ovaritis 
extending  to  the  whole  organ  and  to  all  its  elements :  in  fact,  the 
alterations  are  threefold  -,  they  affect  the  vesicles,  the  parenchyma  and 
the  envelope.  Is  it  always  so  ?  May  the  inflammation  be  limited  to 
one  of  these  tissues  in  place  of  extending  to  all  simultaneously  ?  It 
is  difficult  to  believe  that  it  runs  its  course  in  one  of  these  tissues 

1  Op.  cit.,  p.  392. 

'  Gazette  des  hopitaux,  July,  August,  October,  1869. 


512  UTERINE    DISEASES    IN   DETAIL 

without  affecting  the  others.  However,  I  have  seen  alterations  of  the 
organ  so  limited  to  one  or  other  of  these  elements  that  it  seems  to  me 
beyond  doubt  that  this  anatomo-pathological  distinction  can  be  made : 
in  some  cases  the  peritoneum  covering  the  organ  is  alone  inflamed ; 
adhesions  unite  it  to  the  neighbouring  organs,  and  bands  retain  the 
ovary  in  a  vicious  position,  without  any  real  change  in  the  latter ; 
the  inflammation  may  also  commence  in  a  follicle  and  remain  for  a 
long  time  confined  to  the  membranes  composing  it ;  the  solid  organic 
alterations  so  often  met  with  in  the  ovary  show  us  that  the  starting- 
point  of  the  inflammatory  phenomena  is  at  other  times  limited  to  the 
parenchyma  of  this  organ.^  I  think,  therefore,  we  must  admit  general 
ovaritis  and  partial  ovaritis,  commencing  in  one  of  the  three  elements 
of  the  organ.  Usually  the  latter  soon  extends  to  the  whole  of  the 
ovary,  for  acute  general  ovaritis  is  much  the  most  frequent ;  but  the 
three  forms  usually  co-exist,  and  treatment  can  hardly  vary  even  if 
differential  diagnosis  were  possible. 

A  more  practical  division  is  that  of  five  degrees  of  intensity  in  the 
inflammation  at  five  periods  of  the  malady :  1st  congestion,  2nd  red 
softening,  3rd  induration,  4th  suppuration,  5th  grey  or  gangrenous 
softening. 

Besides  these  alterations,  pathological  anatomy  shows  that  others 
exist,  which  cannot  be  connected  with  any  of  the  five  degrees  enume- 
rated above,  because  several  of  them  are  met  with  in  various  periods 
of  the  malady,  without  belonging  especially  to  any  one  of  them.  Such 
are  displacements  of  the  ovaries,  their  adhesions  to  neighbouring  organs 
(Eallopian  tubes,  uterus,  bladder,  intestine,  &c.),  perforations  of  ovarian 
abscesses,  the  presence  of  pus  in  the  lymphatics  and  in  the  ovarian 
veins,  the  varicose  dilatation  of  veins,  &c.  A  second  remark  is  that 
the  alterations  due  to  inflammation  are  manifested  in  various  degrees 
on  different  points  of  the  ovary  :  adhesion  here,  suppuration  there ; 
induration  at  one  point,  softening  in  another  :  this  depends  not  only 
on  the  course  which  the  malady  follows  in  the  organ,  but  also  on  the 
difference  of  structure  of  the  various  elements  of  which  the  ovary  is 
composed.  One  last  remark :  ovaritis  alone  or  simple  is  excessively 
rare :  the  peritoneum  is  always  affected  like  the  pleura  in  pneumonia ; 
the  Fallopian  tube  participates  almost  always  in  the  inflammation,  the 
uterus  is  often  involved,  primarily  or  consecutively,  the  broad  ligament 
rarely  escaping. 

Etiology. — Ovaritis  is  most  frequently  developed  in  the  puerperal 
state,  and  as  a  consequence  of  menstrual  disorders.  With  the  puer- 
peral state  are  connected  abortions,  hard  labour,  obstetrical  operations, 
want  of  care,  fatigue,  chills,  &c.  With  disturbance  of  the  menstrual 
function  are  connected  all  the  causes  which  increase  catamenial  fluxion 
and  ovarian  congestion,  e.  g.  hot  baths,  eramenagogues,  &c.,  and  those 
which  increase  the  ovarian  congestion  by  suddenly  suppressing  the 
catamenia,  e.g.  coitus  during  menstruation,  a  sudden  chill,  especially 
•of  the  feet  or  lower  part  of  the  body,  emotion,  violent  grief,  &c. 

^  Eveiy  day  brings  additional  proof  of  the  diversity  in  the  seat  of  ovaritis. 
Bouveret,  Annales  de  Gynecologic,  t.  iv,  p.  427. — Darolles,  ibid.,  t.  vi,  p.  419. 


OVARITIS    AND    SALPINGITIS  513 

Ovaritis  is  developed  also  by  the  propagation  of  a  pre-existing 
inflammation  in  the  uterus,  or  of  a  metritis  produced  by  a  traumatism, 
and  even  by  an  inopportune  cauterisation.  Cauterisation  by  causing 
the  metritis  to  pass  from  the  chronic  to  the  acute  stage  leads  to  the 
propagation  of  the  inflammation  to  the  Fallopian  tubes  and  to  the 
ovary.  A  violent  inflammation  of  the  vagina,  especially  if  virulent, 
contagious  and  disposed  to  be  propagated  to  the  uterus  or  to  the  Fal- 
lopian tubes,  may  reach  the  ovaries.  Therefore  ovaritis  may  be  due 
to  the  extension  of  blennorrhagia  to  one  of  the  ovaries,  the  inflammation 
either  reaching  by  degrees  the  internal  parts  of  the  uterine  economy 
including  the  ovary,  or  else  by  a  kind  of  metastasis  favoured  by  a 
natural  sympathy  and  the  vascular  communications  between  these  two 
organs,  it  is  transported  suddenly  from  the  vagina  to  the  ovary,  as  in 
man  from  the  urethra  to  the  testicle.  Ricord  has  described  this  kind 
of  ovaritis  as  comparable  to  blennorrhagic  orchitis.  Bourraud^  has 
related  some  interesting  cases,  and  I  have  seen  some  also. 

Thus  delivery  and  the  puerperal  state,  menstrual  disorders  and  uterine 
inflammation  are  the  principal  causes  of  ovaritis.  Direct  traumatic 
causes  may  also  produce  the  development  of  ovaritis,  but  the  ovary, 
owing  to  its  internal  position  and  mobility,  usually  escapes  their  action. 
The  general  causes  deserve  our  attention.  Maladies  may  attack  the 
ovary  like  other  organs  :  amongst  acute  maladies  we  may  mention 
variola  as  a  sequel  to  which  Beraud^  has  observed  variolous  ovaritis, 
which  he  compares  to  the  variolous  orchitis  described  by  Velpeau  and 
Gosselin ;  amongst  chronic  diseases  we  may  count  scrofula  {see  later, 
on  Tuberculisation  of  the  Ovary),  syphilis  (Nekton  has  mentioned 
syphilitic  ovaritis),  gout  and  rheumatism  (I  have  seen  several  cases  of 
rheumatic  ovaritis). 

According  to  some  physicians,  ovaritis  is  often  double ;  but  Scanzoni^ 
says  that  it  very  often  afi'ects  only  one  ovary,  and  I  can  aflirm  that,  if 
both  are  aff'ected,  one  is  always  much  more  diseased  than  the  other, 
perhaps  the  left  ovary  more  frequently  than  the  right,*  but  the  ovaritis 
on  one  side  does  not  only  coexist  with  ovaritis  on  the  other,  it  coexists 
still  more  frequently  with  inflammation  of  the  Fallopian  tube  or  cor- 
responding broad  ligament. 

Ovaritis  may  be  either  acute  or  chronic ;  it  is  sometimes  difficult  to 
distinguish  the  two  forms,  all  the  more  so  that  chronic  ovaritis  easily 
returns  to  the  acute  stage.  Puerperal  ovaritis  is  the  most  intense  and 
the  most  dangerous  form  of  acute  ovaritis ;  it  often  terminates  fatally 
in  a  few  days.  The  most  persistent  chronic  ovaritis  often  commences 
before  marriage. 

Diagnosis. — The  diagnosis  of  chronic  non-puerperal  ovaritis  in  the 
first  stage  is  difficult,  and  yet  it  is  very  important.  A  girl,  two  or 
three  days  after  her  period  has  commenced,  feels  pain  in  the  iliac  fossa, 
with  radiations,  nausea  and  vomiting;  this  pain  becomes  permanent 

*  Be  I'ovarite  blenorrhagique,  Theses.  Paris,  1847. 

^  Archiv.  gener.  de  Mklecine,  1859,  5*  scrie,  t.  xiii,  p.  588. 

»  Op.  cit.,'p.  399. 

■*  Chereau,  op.  cit.,  p.  155. 

33 


514  UTERINb]    DISEASES    IN    DETAIL 

although  diminished  in  degree,  being  increased  at  the  monthly  period  j 
menstrual  disorders  occur ;  the  patient  is  nervous  and  irritable ;  she 
becomes  emaciated,  a  dark  ring  forms  under  the  eyes,  her  face  is  sallow  ; 
she  probably  has  ovaritis.  Marriage,  often  recommended  with  the  idea 
that  it  will  regulate  menstruation,  increases  the  pain,  leucorrhoea 
is  set  up  and  the  young  wife  is  sterile  :  ovaritis  is  more  and  more 
probable. 

The  importance  of  an  early  diagnosis  is  evident  when  we  think  of 
the  many  dangers  to  which  the  patient  is  exposed  for  want  of  it ;  for 
ovaritis  is  a  much  more  common  disease  than  is  supposed  ;  very  often 
the  ovaries  are  not  examined,  and  very  often  the  uterine  complications 
are  cured  while  the  principal  malady  is  ignored,  ovarian  inflammation 
being  increased  and  suppuration  produced  by  cauterising  the  cervix. 
Uncertainty  of  diagnosis  would  be  less  prejudicial  in  the  latter  case 
than  in  that  of  ovaritis  at  the  commencement.  The  temporary  fluxion, 
the  more  or  less  permanent  congestion  of  the  ovary,  may  indeed  be 
taken  for  the  beginning  of  inflammation  of  this  organ.  It  is  all  the 
more  desirable  to  recognise  and  to  distinguish  them  as  the  treatment 
is  not  identical,  although  necessitated  in  botli  cases  by  the  fear  that 
the  persistence  of  fluxion  or  congestion  may  favour  the  development  of 
inflammation. 

If,  however,  the  diagnosis  of  the  first  stage  is  difficult,  especially  of 
chronic  ovaritis  in  a  girl,  it  is  quite  different  with  confirmed  ovaritis 
especially  of  the  acute  form.  The  obscurity  of  the  diagnosis  depends 
on  two  almost  opposite  causes :  either  on  the  latent  form  or  on  the 
extreme  intensity  of  the  symptoms,  in  fact  on  a  want  of  equilibrium 
which  hinders  observation. 

Peritonitis  especially,  according  to  whether  it  is  developed  or  not, 
may  either  produce  this  intensity  of  symptoms  or  leave  them  in 
obscurity.  Acute  and  chronic  ovaritis  are  very  different  with  regard 
to  the  intensity  of  the  symptoms  and  the  order  of  their  manifestations. 
Puerperal  ovaritis  is  only  the  subacute  form,  generally  accompanied 
by  puerperal  peritonitis. 

Acute  ovaritis — subjective  signs. — Acute  ovaritis  may  from  its  com- 
mencement be  true  acute  ovaro-peritonitis.  Its  reaction  on  the 
organism  is  immediate,  causing  rigor,  fever,  nausea,  vomiting,  pain  more 
or  less  acute,  spontaneous  or  provoked,  often  very  acute  as  in  peritonitis, 
continuous,  but  with  exacerbations  which  may  be  accompanied  by 
hysterical  fits.  Added  to  these  there  is  frequent  desire  for  micturi- 
tion, constipation,  pain  on  going  to  stool,  the  impossibility  of  stand- 
ing J  the  patient  is  almost  bent  double  when  trying  to  walk ;  it  seems 
as  if  a  bar  of  iron  depressed  the  belly,  from  one  iliac  fossa  to  the 
other ;  whilst  raising  the  leg  on  the  affected  side,  and  decubitus  on 
the  healthy  side  cause  acute  pain  followed  by  dragging ;  the  lochial 
and  menstrual  discharges  are  either  suppressed  or  diminished. 

In  simple  acute  ovaritis  the  general  reaction  is  less  ;  sometimes 
there  is  a  little  fever  in  the  evening;  no  vomiting,  but  distaste  for  food, 
dyspepsia,  constipation,  pain  on  going  to  stool  and  at  micturition,  with 
discomfort  at  some    point  of   the  abdomen.     Chereau  describes  the 


OVAEITIS    AND    SALPINGITIS  515 

following  as  symptoms  of  ovaritis  occurring  after  suppression  of  the 
menses  :  aching  in  all  the  limbs,  headache,  thirst,  and  disorders  of 
digestion.  Standing,  walking  on  an  uneven  road,  a  false  step, 
extension  of  the  leg  on  the  same  side  as  the  ovaritis  provoke  pain, 
which  is  still  more  true  of  peri-uterine  inflammation.  The  pain  is  so 
limited,  that  the  patient  may  be  able  to  place  her  finger  on  the  start- 
ing point,  which  is  situated  in  one  of  the  iliac  fossse  above  the  Fal- 
lopian ligament.  From  there  it  radiates  towards  the  hypogastrium, 
the  lumbo-sacral  region,  down  the  thigh  to  the  calf,  sometimes  with 
numbness  of  the  leg. 

The  termination  of  acute  ovaritis  may  be  added  to  the  other  sub- 
jective signs  as  a  help  to  diagnosis.  Ovaro-peritonitis  may  rapidly 
reach  suppuration,  general  peritonitis  and  death;  or  the  phenomena 
may  be  alleviated,  simple  acute  ovaritis  alone  remaining,  with  pre- 
dominance of  local  symptoms.  Eeduced  to  this  degree  it  may  ter- 
minate by  resolution,  in  spite  of  menstrual  exacerbations,  the  only 
termination  which  can  pass  for  a  cure.  It  is  only  obtained  in  acute 
ovaritis  at  the  period  of  congestion ;  it  is  hardly  possible  when  the 
malady  has  reached  the  stage  of  red  softening,  Recovery  may  take 
place  in  from  three  months  to  a  year,  with  the  exception  of  the  per- 
sistence  of  abnormal  sensibility  and  of  some  remains  of  ovarian 
trouble.  Sometimes  it  reaches  suppuration  very  quickly.  The  for- 
mation of  pus  is  announced  by  increase  of  pain,  erratic  rigors,  per- 
spiration in  the  evening,  more  acute  pain  on  pressure,  diffuse  tume- 
faction in  the  pelvis,  or  a  circumscribed  tumour,  rarely  as  large  as  the 
fist,  allowing  obscure  fluctuation  to  be  perceived  when  pressed 
between  the  finger  introduced  into  the  vagina  and  the  hand  placed  on 
the  hypogastrium.  When  pus  is  formed  in  the  ovarian  vesicles  it 
may  remain  encysted  for  a  long  time ;  when  produced  in  the  paren- 
chyma it  makes  more  rapid  progress.  It  may  invade  the  whole  ovary 
without  going  beyond  it,  retained  by  the  fibrous  covering,  the  resist- 
ance of  which  is  increased  by  the  false  membranes  deposited  on  its 
surface  and  forming  a  kind  of  lining.  This  resistance,  increased  by 
that  of  the  adhesions  which  the  ovary  has  contracted  with  the  neigh- 
bouring parts  of  the  serous  membrane,  fortunately  as  a  rule  prevents 
the  abscess  from  opening  into  the  peritoneum. 

Termination  by  suppuration  is  relatively  very  rare,  it  being  only  on 
account  of  the  extreme  frequency  of  ovaritis  that  it  has  been  met  with 
so  often.^  It  is  serious  for  the  ovary,  for  the  neighbouring  organs,  for 
the  whole  organism  which  may  succumb  to  peritonitis  or  pyaemia.  It 
causes  emaciation  and  discoloration  of  the  face.  Additional  adhesions 
are  established  between  the  ovary  and  the  neighbouring  organs  at  each 
succeeding  monthly  period.  Nevertheless  the  sac  of  the  abscess 
becomes  thinner  and  finally  ruptures,  the  pus  being  effused  all  around. 
According  to  Chereau,  Tilt  and  others  the  abscess  generally  opens  into 
the  rectum.     I  have  collected   six   such  cases.     Dupuytren,  Andral, 

'  I  think  there  has  been  an  error  of  diagnosis  in  several  cases ;  it  is  easy  to 
confound  abscess  of  the  ovary  with  inflammation  of  the  broad  ligament  or 
iliac  fossa  ;  abscess  of  the  ovary  often  remains  encysted. 


5]  6  UTERINE   DISEASES    IN    DETAIL 

Montault^  Nauche,  Boivin,  Churchill,  Peudefer,  Bennet  and  others 
have  described  cases  of  the  kind.  Of  all  spontaneous  openings  it  is 
the  most  desirable.  However  more  than  one  patient  has  succumbed 
to  this  accident,  either  immediately  or  after  some  time  from  the  effects 
of  exhaustion  caused  by  the  purulent  secretion.  Bennet^  mentions  the 
case  of  a  girl  of  fourteen,  who  after  having  menstruated  once  or  twice 
was  seized  with  haemorrhage  followed  by  angemia ;  later  on  by  emacia- 
tion, pain  in  the  left  iliac  region,  development  of  the  corresponding 
ovary,  discharge  of  pus  and  death  with  hydrencephalic  symptoms. — 
Opening  into  the  rectum  causes  tenesmus  and  a  kind  of  dysentery 
from  the  contact  of  the  pus  with  the  intestine.  When  the  abscess  is 
not  acute  and  cannot  close  immediately  after  being  emptied,  there  is 
either  an  incessant  excretion  of  pus  or  an  alternation  of  occlusion  with 
opening  of  the  purulent  centre,  giving  rise  to  the  incessant  recurrence 
of  pain,  fever,  and  all  the  accidents  caused  by  each  new  distension  of 
the  abscess  with  pus  and  each  new  laceration  of  the  imperfectly 
cicatrised  wound. 

Opening  of  the  abscess  into  the  vagina  is  rather  less  frequent. 
Husson,  Dance,  Cruveilhier  have  mentioned  cases.  I  have  seen  three. 
This  result  appears  favorable  to  cure ;  only  it  is  sometimes  difficult  to 
discover  the  opening :  we  must  remember  this  when  desirous  of  en- 
larging the  natural  opening,  or  of  making  injections  into  the  cavity  of 
the  abscess. — Exceptionally  ovarian  abscesses  may  open  into  the. 
bladder,  but  this  involves  an  abnormal  position  of  the  inflamed 
ovary.  Andral  and  Murat  have  related  two  cases  and  Gallard  a  third, 
in  which  nothing  was  wanting  but  confirmation  by  necropsy. — The  pus 
may  pass  into  the  oviduct  and  remain  there,  dilating  it  (Laumonier) ,  or 
be  discharged  into  the  uterus  and  thence  externally  (Chambon  de 
Monteaux,  Chereau) ;  or  into  the  body  of  the  uterus,  and  thence  into 
the  vagina  (Boivin). — It  may  make  a  way  for  itself  into  the  csecum 
(Dupuytren),  into  the  colon  (Montault),  or  following  the  round  hga- 
ment  or  the  crural  vessels,  be  discharged  by  the  inguinal  canal  or  by 
the  crural  arch ;  or  after  previous  peritoneal  adhesions  it  may  escape 
through  the  abdominal  parietes,  at  the  iliac  fossa  (I  have  seen  two 
such  cases);  Bennet  (the  Lancet,  July,  1848)  also  mentions  two 
cases. — The  abscess  may  very  exceptionally  open  into  the  peritoneum, 
causing  fatal  peritonitis.  The  pus  has  even  been  seen  to  make  two 
ways  for  itself,  e.g.  by  the  bladder  and  the  uterus  (Boivin). 

After  the  abscess  has  opened,  pus  may  be  reproduced  indefinitely, 
being  discharged  by  the  opening  and  causing  hectic  fever;  the  dis- 
charge is  sometimes  continuous,  sometimes  intermittent,  and  may 
issue  from  several  points  successively.  It  may,  however,  be  cured 
even  after  capillary  puncture,  and  the  general  health  may  be 
restored. 

Objective  signs. — Pressure  from  above  downwards,  on  the  painful 
point  of  the   abdomen,  increases  pain  so   much   as    to  extort  a    cry 
from  the  patient.     Sometimes  the  ovary  may  be  felt  by  abdominal  pal- 
pation :  I  have  often  discovered  it,  high  up,  when  the  patients  felt  it 
'  Neii)  York  Journal,  Sept.,  1846. 


OVAlilTIS    AND    SALPINGITIS  517 

themselves.  It  is  perceived  all  the  more  plainly,  because  often  retained 
on  a  level  with  the  iliac  fossa  by  adhesions. 

The  vagina  is  hot,  sometimes  dry,  sometimes  moist ;  the  uterus  fre- 
quently deviated,  but  not  so  much  so  as  in  hematocele ;  the  cervix 
having  variable  disorders,  being  usually  engorged  or  oedematous.  The 
uterus  has  lost  part  of  its  mobility  owing  to  adhesions  between  the 
ovary  and  the  neighbouring  organs ;  in  one  direction  especially  it  has 
become  fixed ;  when  we  try  to  remove  it  from  the  diseased  ovary  great 
pain  is  elicited. 

In  the  vaginal  cul-de-sac  answering  to  the  abnormal  fixity  of  the 
uterus  the  finger  sometimes  encounters  resistance,  sometimes  a  small 
tumour ;  at  this  point  resistance  is  experienced  and  excruciating  pain 
sometimes  produced  by  pressure.  It  is  by  rectal  touch,  however,  in 
following  the  lateral  borders  of  the  uterus  that  we  can  best  discover  a 
tumour  of  the  size  of  a  nut  or  a  small  egs,,  very  painful,  the  situation 
of  which  is  variable,  depending  on  the  point  at  which  the  inflamed 
ovary  is  adherent;  by  associating  abdominal  palpation  with  touch  a 
still  more  precise  diagnosis  can  be  made. 

Chronic  ovaritis — subjective  signs. — The  pain  which  Scanzoni  de- 
scribes as  a  disagreeable  sensation  is  not  always  so  acute  as  has  been 
said;  it  is  sometimes  sharp,  sometimes  burning,  extending  up  the 
loins  during  menstruation :  patients  say  that  it  seems  to  them  as  if  a 
hot  coal  were  placed  in  the  pelvis.  It  continues  in  a  modified  degree 
during  the  intercalary  period;  it  causes  permanent  discomfort  with 
darting  exacerbations  after  exercise  or  fatigue.  It  is  in  the  middle  of 
or  a  little  above  the  fold  of  the  groin,  not  extending  to  the  iliac  fossa 
nor  generally  causing  tension  of  the  abdominal  parietes.  It  radiates 
from  this  point,  principally  along  the  corresponding  thigh  to  the  knee, 
causing  numbness  or  even  coldness  of  the  leg ;  it  is  increased  by  walk- 
ing, standing,  rising,  effort  of  any  kind,  pressure  from  above  down- 
wards, coitus  and  menstruation.  In  cases  where  the  ovary  adheres  to 
the  posterior  surface  of  the  lower  border  of  the  uterus,  so  that  the 
penis  touches  it  during  coitus,  such  terrible  pain  is  caused  that  inter- 
course becomes  impossible.  This  pain  is  particularly  sharp  some  days 
after  menstruation,  or  for  one  or  two  days  before  it,  and  very  often  is 
not  alleviated  by  the  catamenial  flow.  The  first  symptoms  of  chronic 
ovaritis  are  menstrual  disorders^  menorrhagia  or  amenorrhoea,  or 
menorrhagia  and  amenorrhoea  may  alternate  with  pain  in  the  ovarian 
region  during  the  period,  a  symptom  often  occurring  in  young  girls. 
These  disorders  seldom  consist  in  amenorrhcea,  but  rather  in  a  diminu- 
tion, delay,  or  suppression  of  some  months.  In  some  chronic  cases 
there  is  menorrhagia,  hsemorrhage  even  occurring  in  the  intermen- 
strual period,  which  is  always  in  advance;  but  in  that  case  there  is 
also  metritis,  or  at  least  leucorrhoea,  itching,  heat,  with  vulval  and 
vaginal  desquamation.  The  symptoms  of  neighbourhood  are  :  frequent 
desire  for  micturition,  scalding  urine  loaded  with  urates  and  phos- 
phates, constipation,  hsemorrhoidal  tumours,  tenesmus,  uterine  colics, 
constriction  of  the  vagina  or  vulva.  These  are  often  unimportant  on 
account  of  the  small  size  of  the  tumour.     The  general  subjective  signs 


518  UTERINE    DISEASES    IN    DETAIL 

are  those  of  chronic  metritis,  but  more  numerous  and  occurring  more 
rapidly  and  perhaps  still  more  marked,  especially  those  of  the  nervous 
system.  Disordered  digestion  causes  nausea,  sympathetic  vomiting, 
principally  at  the  commencement  of  the  malady  or  at  the  time  of  the 
painful  attacks ;  it  causes  epigastric  sensibility,  loss  of  appetite,  ema- 
ciation, depression,  suffering,  paleness,  palpitation,  breathlessness, 
arterial  pulsation,  fainting,  in  short  chloro-aiiEemia,  especially  in  patients 
suffering  from  leucorrhoea  and  menorrhagia.  Disorders  of  the  nervous 
system  are  not  less  serious.  Diseases  of  the  ovaries  like  those  of  the 
testicles,  seem  to  affect  the  patient  morally  still  more  than  do  those  of 
the  uterus.  Women  so  affected  become  morbidly  sensitive;  they 
experience  an  indefinable  discomfort  and  suffer  from  erratic  pains  on 
the  track  of  the  intercostal,  lumbar  and  sacral  nerves,  principally  on 
the  left  side,  with  painful  irradiations  into  the  corresponding  leg; 
spasms  of  the  pharynx,  glottis  and  sphincters  of  the  bladder,  anus  and 
vulva  and  various  hysterical  phenomena  such  as  hypersesthesia  and 
anaesthesia,  in  fact  all  the  cortege  of  hysteria  except  the  convulsive  fits, 
which  are  rare.  The  gravity  of  these  symptoms  is  not  surprising 
when  we  remember  that  of  all  the  maladies  of  the  uterine  system, 
chronic  ovaritis  is  one  of  those  which  furnishes  the  most  dangerous 
cases. 

Ovaritis  primarily  chronic  has  an  extremely  slow  course,  but  it  is 
increased  by  menstruation  and  coitus.  There  is  exacerbation  at  every 
monthly  period,  till  at  last  fever  breaks  out,  and  pain  increases  so  as 
to  become  intolerable.  This  passage  to  the  acute  state  is  serious, 
because  it  sometimes  determines  formidable  accidents :  the  rupture  of 
an  ovarian  abscess,  circumscribed  peritonitis  becoming  generalised  on 
the  slightest  cause,  increasing  debility,  pysemia  itself  and  finally  death. 
Aran  gives  the  case  of  a  woman  in  whom  the  introduction  of  a  pessary 
led  to  these  fatal  results.  Whilst  an  inflammatory  centre  exists  in  the 
ovary  or  in  one  of  the  pelvic  organs,  an  acute  attack  may  occur 
at  any  moment.  A  more  gradual  but  not  less  dangerous  conse- 
quence of  ovaritis  is  the  development  of  a  cyst.  But  even  when  it 
does  not  pass  to  the  acute  form  causing  perimetritis  or  general  perito- 
nitis, chronic  ovaritis,  owing  to  its  duration,  has  not  the  less  serious 
consequences :  the  gradual  debility  of  patients  and  the  serious  disturb- 
ance of  their  general  health  dispose  them  to  contract  other  diseases, 
and  expose  them  to  the  attacks  of  the  various  diatheses,  especially  the 
tuberculous. 

Supposing  the  patient  escapes  all  these  dangers,  chronic  ovaritis 
may  terminate  by  induration  and  atrophy.  This  transformation  of  the 
organ  is  not  strictly  speaking  a  cure ;  but  it  may  cause  the  cessation 
of  painful  phenomena  and  the  general  disturbance  of  health.  Follow- 
ing red  softening,  it  is  characterised  by  a  hyperplasia  and  a  new 
formation  of  connective  tissue ;  this  tissue  ends  by  stifling  the  other 
elements :  the  ovary  either  remains  voluminous  while  becoming  fibrous 
or  cartilaginous,  or  it  may  atrophy  and  shrink,  the  ovarian  vesicles 
and  ovules  disappearing.  The  small  vesicles  as  well  as  the  large  are 
surrounded  by  peritoneal  adhesions,  the  visible  remains  of  the  inflam- 


OVARITIS    AND    SALPINGITIS  519 

mation  which  has  caused  the  degeneration.  Fatty  degeneration  may 
also  produce  atrophy.  Wlien  both  ovaries  are  affected  complete  and 
irremediable  sterility  is  the  result,  for  the  malady  goes  on  increasing 
with  time  in  place  of  being  cured. 

Objective  signs. — Palpation  is  insufficient,  for,  as  in  acute  ovaritis, 
the  ovary  is  hidden  in  the  pelvis,  lying  close  to  the  uterus  or  adhering 
to  it.  The  small  size  of  the  tumour  allows  of  its  escaping  observation 
in  a  superficial  examination.  Vaginal  and  rectal  touch  alone  lead  to 
diagnosis.  The  passage  of  the  finger  through  the  vulva  sometimes 
provokes  very  acute  pain,  on  account  of  the  contraction  of  the 
sphincters.  The  vagina  is  very  rarely  hot  and  is  often  moist  from 
mucus.  The  cervix  looks  healthy,  half  open,  and  somewhat  cedema- 
tous.  Usually  the  uterus  is  inclined  to  one  side,  its  mobility  being 
diminished ;  it  is  impossible  to  pusb  it  from  the  painful  to  the 
opposite  side  without  causing  dragging,  which  increases  the  pain  as 
well  as  the  curve  existing  in  the  corresponding  vaginal  cul-de-sac,  but 
without  allowing  the  discovery  of  an  indistinctly  circumscribed 
tumour  which  can  only  be  diagnosed  by  rectal  touch.  The  inflamed 
ovary  is  more  accessible  to  our  investigations  than  the  healthy  one,  on 
account  of  its  size  and  weight  which  make  it  fall  behind  the  uterus, 
retroverting  the  latter  slightly.  This  displacement  of  the  ovary  into 
the  posterior  cul-de-sac  may  be  considered  as  the  rule  though  there 
are  numerous  exceptions.  The  diseased  ovary,  whilst  descending 
lower  than  the  healthy  one,  is  prevented  by  the  utero-ovarian  liga- 
ment from  being  precipitated  to  the  bottom  of  the  posterior  peritoneal 
cul-de-sac  :  it  is  situated  behind  and  on  one  side  of  the  uterus  answer- 
ing to  the  vaginal  insertions  of  the  cervix  where  it  may  be  retained  by 
adhesions.  Hence  a  dragging  on  the  uterus,  and  a  slight  unsteadi- 
ness of  this  organ;  if  this  slight  retroversion  is  not  produced,  the 
ovary  remains  elevated.  Hence  the  utility  of  rectal  touch  so  strongly 
recommended  by  Lowenhardt,  of  Preslaw,  in  1835,  and  since  then  by 
Lisfranc,  Aran,  and  all  gynsecologists ;  hence  also  the  importance  of 
the  association  of  rectal  with  vaginal  touch  recommended  by  Gallard.^ 
Unless  adhesions  keep  the  ovary  in  place,  this  organ  escapes  from  the 
simultaneous  pressure  exercised  by  the  two  fingers  that  have  seized  it. 
We  may  add  that,  in  order  that  the  fiogers  may  reach  and  seize  the 
retro-uterine  tumour  supposed  to  be  the  ovary,  hypogastric  pressure 
must  be  combined  with  this  double  touch  in  order  to  press  the  viscera 
into  the  pelvic  cavity. 

By  what  signs  can  we  know  that  this  tumour  is  really  the  ovary  ? 
It  is  an  ovoid  body,  sometimes  elongated,  a  little  flattened  from  before 
backwards,  adhering  to  the  lateral  or  posterior  part  of  the  uterus,  or 
separated  from  this  organ  by  a  more  or  less  deep  groove,  sometimes 
mobile,  sometimes  not.  In  consistency  it  is  hardly  elastic,  never 
indurated ;  its  surface,  sometimes  smooth  and  polished,  sometimes 
indented  and  irregular,  sometimes  elastic,  is  usually  rounded  and 
resistant.  The  sensibility  is  extreme  and  is  revealed  by  pressure, 
sometimes  causing  acute  pain;  for  notwithstanding  what  has  been  said 
'  Gazette  des  hopitaiix,  July,  August,  1869. 


520  UTERINE    DISEASES    IN   DETAIL 

by  some  writers,  the  ovary  is  very  sensitive  normally,  and  when  this 
sensibility  is  increased  by  inflammation,  pressure  becomes  most 
painful.  The  greater  size  of  the  tumours  of  ovaritis  prevent  their  being 
confounded  with  those  of  retro-uterine  adenitis  which  occupies  almost 
the  same  place  and  is  also  very  painful. 

Differential  diagnosis. — Ovaritis  must  be  distinguished :  1,  from 
other  ovarian  diseases ;  ?-,  from  uterine  and  peri-uterine  diseases. 

1.  The  ovarian  diseases  which  have  to  be  distinguished  from 
ovaritis  are  fluxion,  congestion,  cedema,  apoplexy,  engorgement, 
hypertrophy,  &c.  Morbid  fluxion  of  the  ovaries,  like  that  of  the 
uterus,  occurs  chiefly  at  puberty,  at  menstruation,  on  the  occasion  of 
venereal  orgasm,  &c.  It  exceeds  the  fluxion  which  is  normal  to  those 
organs  under  such  circumstances.  It  is  manifested  not  only  by  pain, 
but  also  by  stronger  venereal  excitement,  discomfort  in  the  iliac  and 
lumbar  regions,  symptoms  of  neighbourhood,  &c.  Ovarian  conges- 
tion may  be  met  with  in  girls ;  it  is  sometimes  produced  by  a  con- 
genital tendency,  or  in  consequence  of  the  sudden  suppression  of  the 
menses,  or  of  the  existence  of  dysmenorrhoea ;  it  persists  or  is  repro- 
duced under  the  influence  of  a  general  state  such  as  plethora, 
impoverished  constitution,  &c.,  or  from  a  diathetic  affection  such  as 
rheumatism.  It  has  many  symptoms  in  common  with  uterine  con- 
gestion (pain,  heat,  persistent  discomfort  in  the  iliac  region  and  in  the 
cavity),  and  as  the  latter  difi'ers  from  metritis,  so  ovarian  congestion 
difi'ers  from  ovaritis  in  the  symptoms  being  less  acute  and  continuous; 
the  heat  is  less  intense  and  the  pain  less  excruciating,  even  when 
provoked  by  compressing  the  organ  directly. 

Serous  infiltration,  a  kind  of  oedema  of  the  ovary,  has  been 
described  by  Morgagni^  as  occurring  in  a  woman  who  succumbed 
after  delivery.  According  to  Cruveilhier  ^  it  must  not  be  confounded 
with  ovarian  inflammation  ;  but  it  seems  to  me  difBcult  to  distinguish 
it  from  the  softening  which  characterises  one  of  the  stages  of  this 
inflammation  and  which  may  be  accompanied  by  an  interstitial  san- 
guineous effusion  followed  by  the  coagulation  of  the  fibrin  and  infil- 
tration of  a  yellowish  serosity  between  the  tissues  of  the  organ. 

Haemorrhage  of  the  ovaries  may  be  interstitial  or  vesicular,  may  take 
place  slowly  or  suddenly  (apoplexy),  be  contained  within  the  envelope 
of  the  organ  or  be  effused  externally  (hematocele),  may  accompany 
other  lesions  or  result  from  a  simple  alteration  of  the  vascular  system 
(congestion,  lacerations  of  the  capillaries,  &c.).  It  usually  occurs 
suddenly  during  the  menstrual  period,  after  physical  or  moral  emotion, 
on  the  occasion  of  venereal  excesses,  sometimes  during  pregnancy. 
The  sudden  appearance  of  symptoms  of  peritonitis  added  to  those  of 
internal  haemorrhage  distinguishes  haemorrhages  with  effusion  of  blood 
into  the  peritoneum  from  interstitial  haemorrhages  and  from  simple 
ovaritis. 

Does  engorgement  exist  ?  Is  it  a  step  towards  induration,  described 
as  one  of  the  terminations  of  inflammation  and   as   characteristic  of 

'  De  sedibxis,  &c.  Epist.  xlvi,  §.  27. 

^  Anatomie pathologique,  13^  liv.,  p.  13. 


OVAEITIS    AND    SALPINGITIS  521 

chronic  ovaritis  ?     It  is  difficult  to  judge  the  question,  and  still  more 
so  to  diagnose  such  a  morbid  state. 

Hypertrophy  may  either  affect  all  the  various  elements  of  the  ovary 
or  each  separately.  In  describing  organic  lesions  we  shall  see  that  it 
gives  rise  not  only  to  unilocular  and  multilocular  cysts,  to  cysto- 
fibromata,  to  cysto-sarcomata,  but  also  to  simple  fibromata,  and  that 
the  ovary,  by  hypertrophy  of  the  fibrous  tissue  and  atrophy  of  the 
Graafian  vesicles,  may  be  transformed  into  a  more  or  less  voluminous 
body,  hard,  compact,  fibrous,  fibro-cartilaginous  and  even  stony  at 
some  points.  These  transformations  may  be  consecutive  to  ovaritis. 
The  slow  development,  the  tumour,  the  tolerance  of  the  malady  by  the 
organism  are  the  elements  of  a  difi'erential  diagnosis  between  these 
degenerations  and  ovaritis  strictly  so  called.  Tubercle  and  cancer  are 
not  so  well  tolerated ;  in  addition  to  the  symptoms  of  ovaritis  there 
are  the  local  symptoms  produced  by  the  increased  size  of  the  ovary  or 
the  extension  of  the  malady  to  the  neighbouring  organs,  and  the  general 
symptoms  resulting  from  the  progress  of  cachexy. 

Ovarian  neuralgia  is  distinguished  by  the  absence  of  all  signs  of 
inflammation  except  pain ;  this  pain  itself  has  special  characters  :  it  is 
excruciating,  it  darts  upwards  to  the  loins  and  sometimes  downwards 
to  the  vagina,  urethra,  and  pubic  symphysis ;  it  is  not  increased  by 
pressure,  frequently  even  appearing  to  be  diminished  by  sustained 
pressure  ;  the  ovary  cannot  be  reached  per  vaginam,  for  it  does  not 
usually  descend  as  in  ovaritis,  but  seems  on  the  contrary  in  some 
patients  rather  to  have  ascended  ;  the  pain  may  be  strong  enough  to  de- 
termine nausea,  vomiting  or  hysterical  symptoms ;  it  comes  by  fits,  not 
always  coinciding  with  the  monthly  period  ;  it  is  often  accompanied  by 
neuralgia  in  other  regions,  especially  by  lumbo-abdominal  neuralgia. 
Lastly,  a  suppurating  cyst  must  not  be  confounded  with  an  abscess 
resulting  from  ovaritis.  The  cyst  is  always  much  larger  than  the 
abscess ;  it  has  no  tendency  to  open  spontaneously ;  it  is  situated  in 
the  abdomen  in  place  of  being  contained  in  the  pelvis ;  it  has  given 
signs  of  its  presence  and  developed  to  some  extent  before  suppurating ; 
the  local  and  general  symptoms  of  inflammation  and  of  the  formation 
of  pus  have  therefore  followed  the  development  of  the  tumour  in  place 
of  preceding  it.  Besides  those  cysts  the  internal  membrane  of  which 
becomes  inflamed  and  suppurates  after  puncture,  there  are  some  which 
are  primarily  purulent.  I  once  removed  an  ovarian  cyst  which  con- 
tained nothing  but  pus;  it  was  formed  after  delivery;  everything  was 
going  on  well  till  the  eleventh  day,  when  the  patient  succumbed  to 
serous  diarrhoea. 

2.  Ovaritis  must  also  be  distinguished  from  uterine  and  peri-uterine 
inflammation.  Not  only  may  ovaritis  be  confounded  with  maladies  of 
the  neighbouring  organs,  but  it  is  also  almost  necessarily  accompanied 
by  inflammation  of  the  Pallopian  tube  and  peritoneum.  The  frequency 
of  ovaritis  has  been  exaggerated  by  Boivin  and  Duges,  Chereau  and 
Lisfranc,  whilst  that  of  peri-uterine  inflammation,  abscesses  of  the  broad 
ligaments  and  pelvic  peritonitis  has  been  exaggerated  by  more  modern 
practitioners.     For  while  it  is  easy  to  diagnose  a  retro-uterine  phlegmon 


522  UTERINE    DISEASES   IK   DETAIL 

it  is  very  difficult  to  distinguish  a'  lateral  one  from  ovaritis.  It  is  cer- 
tain that  in  a  number  of  cases  peri-uterine  phlegmasias  are  constituted, 
as  we  shall  afterwards  show,  by  inflammation  of  the  peri-uterine  cel- 
lular tissue,  of  the  pelvic  peritoneum,  ovary  and  Fallopian  tube,  or 
even  of  the  uterus,  without  its  being  possible  to  establish  exactly 
which  tissue  was  first  affected  and  which  most  acutely  inflamed. 

Neuralgia,  especially  lumbo-abdominal  neuralgia,  presents  circum- 
scribed points  of  pain  which  do  not  exist  in  simple  ovaritis.  Metritis 
is  distinguished  from  ovaritis  by  the  following  characteristics  :  the 
pain  is  median,  sharp,  increased  by  pressure,  especially  by  bimanual 
palpation,  and  also  by  movements  transmitted  to  the  organ,  which  is 
not  the  case  in  ovaritis,  unless  the  body  of  the  uterus  is  pressed 
against  the  inflamed  ovary. 

Peritonitis  is  characterised  by  acute  pain  produced  by  the  slightest 
contact  and  forbidding  any  thorough  examination  by  pressure  of  the 
abdominal  parietes  or  by  vaginal  touch.  In  place  of  simple  nausea 
or  vomiting  of  food  there  is  bilious  green  vomiting,  hiccough,  &c.  A 
peri-uterine  phlegmon  determines  a  considerable  elevation  of  the  tem- 
perature of  the  vagina,  puffiness  of  the  tissues,  which  are  hard  and 
resistant  although  oedematous  and  the  formation  of  a  tumour  which  is 
fixed  and  does  not  fly  from  the  finger,  adhering  to  the  neighbouring 
tissues  and  making  them  adhere  together.  The  uterus  is  no  longer 
mobile,  but  fixed  in  the  midst  of  inflamed  tissues.  The  tumour  pro- 
jects into  the  vagina,  forming  a  protuberance  all  round  the  cervix  or 
in  one  of  the  culs-de-sac  which  becomes  eff'aced ;  it  presents  arterial 
pulsation  on  its  surface.  Retro-  or  peri-uterine  adenitis,  whilst  occu- 
pying almost  the  same  place,  is  less  extensive  than  ovaritis;  I  do  not 
doubt,  however,  that  it  has  sometimes  been  confounded  with  it.  In 
addition  to  the  difference  of  size,  the  simultaneous  presence  of  analo- 
gous small  tumours  in  the  neighbourhood  should  allow  of  its  being 
distinguished. 

I  must  now  indicate  the  differential  characters  which  enable  us  to 
distinguish  chronic  ovaritis  or  an  ovarian  abscess  from  a  pelvic  abscess 
or  from  a  phlegmon  of  the  iliac  fossa.  The  form  of  the  tumour  and 
its  relations  facilitate  this  distinction.  The  form  of  the  tumour  is 
ovoid  and  circumscribed  in  place  of  being  diffused ;  its  relations  with 
the  neighbouring  parts  are  more  clearly  defined ;  there  exists  a  more 
or  less  marked  interval  between  the  tumour  formed  by  the  ovary  and 
the  pelvic  organs  or  ilium.  We  must,  however,  remember  that  these 
characters  disappear  as  soon  as  the  ovaritis  has  determined  around  it, 
as  frequently  happens,  more  or  less  extensive  pelvic  peritonitis  with 
suppuration,  or  at  least  exudation,  adhesions,  &c. 

Treatment. — It  cannot  be  denied  that  acute  ovaritis  is  one  of  the 
most  dangerous  of  diseases,  while  chronic  ovaritis  is  one  of  the  most 
difficult  to  treat  and  to  cure,  and  that  during  its  whole  course  it  ex- 
poses patients  to  continual  danger  from  peritonitis.  Therefore  it  must 
be  treated  in  spite  of  its  reputed  character  of  being  incurable ;  for  even 
if  treatment  is  insufficient  to  restore  the  organ  to  its  original  integrity 
it  may  at  least  prevent  serious  terminations  and  enable  the  system 


OVARITIS    AND    SALPINGITIS  523 

to  tolerate  the  malady.  Lastly,  by  the  alterations  which  it  determines 
in  the  ovary  or  the  vicious  adhesions  which  it  establishes  between  this 
organ  and  the  neighbouring  parts,  it  becomes  an  almost  incurable 
cause  of  sterility  :  an  additional  reason  for  treating  it  intelligently  and 
energetically.  In  the  treatment  of  ovaritis  especially  patients  must  be 
warned  that  months  and  years  are  required  to  effect  a  cure. 

As  a  rule  perfect  rest  should  be  prescribed  for  the  genital  system, 
even  in  the  treatment  of  chronic  ovaritis ;  but  exceptions  may  be 
made  in  the  case  of  some  women  as  described  at  page  167.  As  for 
the  desirability  of  marriage  as  advised  by  Gallard  for  girls  suffering 
from  commencing  ovaritis,  with  the  double  view  of  preventing  sterility 
(which  the  malady  could  not  fail  to  produce  at  a  later  period)  and  of 
favouring  resolution  (by  the  repose  from  ovulation  given  to  the  organ 
during  the  nine  months  of  pregnancy),  I  think  it  is  important  to 
make  the  distinction  between  inflammation  of  the  ovary  strictly  so 
called,  which  is  always  aggravated  by  marital  intercourse,  and  the 
simple  congestion  or  fluxion  of  this  organ  which  not  only  can  tolerate 
coitus,  but  may  be  favorably  influenced  by  pregnancy. 

The  indications  for  treatment  are  reduced  to  the  two  following :  to 
subdue  the  inflammation  by  antiphlogistic  treatment  proportioned  to 
its  intensity ;  to  promote  resolution  of  the  diseased  ovary  and  of  the 
plastic  products  formed  in  its  parenchyma  or  around  it,  and  if  neces- 
sary to  evacuate  pus,  while  supporting  the  strength  of  patients, 
favouring  nutrition  and  restoring  the  constitution. 

I.  Antip/dogistic  treatment  ought  to  be  proportioned  to  the  intensity 
and  to  the  complications  of  the  acute  form.  In  acute  ovaritis  compli- 
cated with  peritonitis,  in  ovaro- peritonitis  properly  so  called,  it  cannot 
be  too  energetic.  In  simple  acute  and  in  chronic  ovaritis,  the  long 
continued  use  of  the  same  means  should  be  substituted  for  the  energy 
used  during  a  few  days  in  complicated  acute  ovaritis.  Bloodletting 
constitutes  the  first  and  the  most  energetic  means.  Bleeding  is  seldom 
indicated ;  but  leeches  and  scarifications  may  be  applied  largd  manu, 
and  repeated  at  longer  or  shorter  intervals  according  to  the  case. 

In  superacute  ovaritis,  15  or  30  leeches  may  be  applied  to  the 
ihac  fossa  or  hypogastrium,  or  the  scarificator  may  be  used,  so  as  to 
keep  up  a  flow  of  blood  for  some  hours.  The  perfect  calm  following 
this  first  application  and  the  use  of  other  means  must  be  distrusted. 
When  abdominal  palpation  causes  pain,  or  if  in  the  absence  of  this 
sign  the  temperature  of  the  vagina  continues  high,  and  the  tumour 
occupying  the  lateral  portion  of  the  pelvis  outside  the  uterus  is  still 
sensitive  to  pressure,  bloodletting  should  again  be  resorted  to.  If 
necessary,  leeches  and  the  scarificator  may  be  applied  three  or  four  days 
successively,  diminishing  the  number  each  day.  In  simple  acute  and 
in  chronic  ovaritis,  the  diminution  of  pain  allows  of  the  application  of 
leeches  not  only  to  the  abdomen  but  to  the  cervix,  which  is  preferable, 
because  depletion  of  the  utero-ovarian  vascular  system  being  quicker 
a  smaller  number  of  leeches  produces  more  effect,  besides  which 
ovaritis  is  frequently  accompanied  by  hypersemia  of  the  uterus  or  even 
by  metritis.     Alleviation  is  often  immediate;  but  sometimes  on  the 


524  UTERINE    DISEASES    IN    DETAIL 

contrary  fresh  applications  must  be  made  several  days  running  or  at 
short  intervals.  In  chronic  ovaritis  it  is  well,  as  a  rule,  to  leave  an 
interval  of  a  month  at  least  between  two  consecutive  applications,  and 
they  should  always  be  made  immediately  after  and  not  before  men- 
struation. We  must  take  advantage  of  the  time  when  menstrual  con- 
gestion has  terminated,  to  empty  the  utero-ovarian  vascular  system. 
If  the  patient  is  plethoric  and  it  is  desirable  to  bleed  before  the 
monthly  period,  blood  should  be  drawn  from  the  arm  as  a  means  of 
revulsion  to  prevent  the  approaching  catamenia  from  being  as  consi- 
derable as  usual. 

The  application  of  leeches  in  cases  of  subacute  ovaritis  should  be 
immediately  followed  by  the  use  of  auxiliary  means,  such  as  rest, 
diluents,  emollient  and  sedative  cataplasms,  an  emeto-cathartic  if  there 
is  gastric  derangement,  or  a  simple  laxative  or  enema  if  there  is  intes- 
tinal irritation,  and  sedatives  and  resolvents  in  peritonitis,  i.  e.  opium 
and  mercurial  frictions.  There  need  be  no  fear  of  giving  opium  in 
large  doses  if  the  precaution  is  taken  to  administer  it  less  frequently 
as  soon  as  a  sedative  effect  is  produced,  and  to  cease  it  entirely  if  the 
patient  shows  a  tendency  to  remain  drowsy.  Here  as  in  other  cases, 
opium  may  when  necessary  be  replaced  by  morphia  either  administered 
internally  or  by  hypodermic  injection,  but  opium  when  tolerated  is 
preferable.  It  is  of  course  needless  to  employ  it  in  chronic  ovaritis. 
Frictions  should  be  made  with  mercurial  and  belladonna  ointment. 
On  such  occasions  it  should  be  used  like  leeches  laj'ffd  manu,  i.  e.  one 
ounce  of  ointment  should  be  spread  on  the  abdomen  every  five  or  six 
hours,  and  covered  by  a  large  poultice  of  linseed  meal  hot  and  very 
moist,  in  which  a  few  drops  of  laudanum  may  be  sprinkled.  A  thick 
layer  of  cotton  wool  should  be  placed  over  this  with  oil  silk  above  all. 
The  following  morning  patients  take  a  bath,  and  after  having  dried 
the  abdomen  well  keep  it  covered  all  day  with  a  flannel  bandage  unless 
there  is  an  indication  to  have  the  belly  constantly  covered  with 
ointment  and  cotton  wool  to  keep  up  a  moist  heat  favorable  to 
resolution. 

Baths  and  irrigations  are  valuable  auxiliaries  which  should  be  pre- 
scribed as  soon  as  they  can  be  used  without  fatigue  to  patients.  We 
begin  with  prolonged  warm  general  baths  (emollient,  gelatinous  or 
alkaline)  with  vaginal  irrigation  every  day  or  every  other  day;  they 
should  soon  be  replaced  by  hot  irrigations.  At  a  later  period,  though 
rarely  in  cases  of  chronic  ovaritis  without  exacerbation,  tepid  and  cold 
sitz-baths  may  be  substituted  with  cold  irrigations  and  enemata, 
which  constitute  a  suitable  means  for  subduing  the  continual  tendency 
to  renewed  fluxion  towards  the  ovary,  and  for  facilitating  resolution 
of  the  chronic  phlegmasy  by  their  tonic  and  slightly  revulsive  action 
on  the  skin. 

II.  Resolvent  medication  ought  to  follow  antiphlogistic  treatment 
especially  in  chronic  ovaritis ;  it  should  be  continued  for  a  long  time, 
for  it  requires  months  and  even  years  to  obtain  a  cure.  We  can 
measure  the  progress  made  towards  health  by  the  amelioration  eff"ected 
in  the  performance  of  the  menstrual  function. 


OVARITIS    AND    SALPINGITIS  525 

Resolvent  medication  consists  in  the  internal  use  of  alteratives,  mer- 
curials, iodide  of  potassium,  oxide  of  gold,  &c.;  and  of  the  external 
use  of  the  same  medicaments,  frictions  of  mercurial  ointment,  tincture 
of  iodine,  and  even  blisters,  the  utility  of  which  is  undoubted,  although 
not  equally  successful  in  all  patients,  and  less  so  in  cases  of  ovaritis 
than  in  peri- uterine  inflammation  or  pelvic  phlegmon  ;  cauterisation  is 
preferable,  and  igni-punctures  from  being  less  painful  and  causing  less 
cicatricial  deformity  are  doubly  preferable,  because  they  can  be  resorted 
to  again.  In  cases  of  ovaritis  I  have  found  the  use  of  rectal  injections 
of  resolvent  ointment  of  great  use  :  this  means  is  very  superior  to  sup- 
positories, as  it  enables  us  to  apply  the  medicament  in  sufficient 
quantity  to  the  diseased  organ  and  to  vary  the  composition  according 
to  the  condition  and  tolerance  of  the  patient.  We  must  also  remember 
that  the  choice  of  these  medicaments  is  not  indifferent,  that  after  in- 
flammation is  once  fixed  in  the  ovary  the  organ  often  remains  diseased, 
in  spite  of  the  most  energetic  and  most  rational  antiphlogistic  treat- 
ment, because  this  inflammation  has  sufficed  to  determine  on  the  ovary 
the  localisation  of  a  diathetic  condition  to  the  cure  of  which  even 
ovaritis  is  secondary. 

In  chronic  ovaritis  I  have  frequently  observed  what  I  have  also 
remarked  in  orchitis  :  that  the  rheumatic,  herpetic,  scrofulous  or 
tuberculous  diathesis  may  localise  itself  on  the  diseased  ovary  and  keep 
up  hypersemia,  fluxion,  prolonged  pain,  or  produce  still  more  serious 
alterations.  Copland^  has  described  rheumatic  ovaritis,  giving  two 
cases;  Gallard^  has  published  another;  and  1  have  collected  several. 
Henry  Bennet^  describes  a  case  of  death  due  to  a  tuberculous  deposit 
in  the  ovary  ;  in  three  cases  of  the  same  kind  the  pus  made  way  for 
itself  through  the  abdominal  wall.  It  is  evident  that  the  means  of 
treatment  ought  to  vary  according  to  the  nature  of  the  diathetic  affec- 
tion, which  takes  a  more  or  less  considerable  part  in  the  prolongation 
of  the  ovaritis.  For  instance  I  have  succeeded  in  curing  chronic 
ovaritis  of  two  years'  duration  in  a  very  scrofulous  woman  by  iodide 
of  potassium  in  large  doses,  followed  by  the  administration  of  oxide  of 
gold  continued  for  a  long  time,  associated  with  residence  at  the  sea- 
side during  the  summer,  the  patient  taking  two  baths  a  day  and  resting 
for  eight  days  every  month.  I  have  cured  three  cases  of  chronic  ova- 
ritis with  sulphur  water  taken  internally  as  well  as  in  baths,  combined 
with  cold  douches  on  the  loins,  in  which  alkaline  baths,  associated 
with  the  ordinary  resolvents,  had  produced  no  effect.  In  one  case, 
about  which  I  was  almost  in  despair  as  to  the  cause  (there  only  being 
very  slight  external  manifestations  of  the  herpetic  diathesis),  I  tried 
arsenical  preparations  followed  by  a  season  at  Avene  (Herault)  and 
was  successful. 

The  addition  of  carbonate  of  soda  or  sea-salt  to  sitz-baths  may  be 
made  when  acute  ovaritis  passes  into  the  chronic  stage.  General 
baths  (alkaline  or  chlorinated,  or  both),  natural  waters  such  as  those 

'   Gazette  mf-dicale  de  Paris,  1830,  p.  302. 
^  Gazette  des  hnpitaux,  October,  1869. 
^  The  Lancet,  July,  1848. 


526  UTEEINE   DISEASES    IN    DETAIL 

of  Plombieres,  Vichy,  Vals  and  Boulou,  purgatives  from  time  to  time, 
irrigations  with  cold  water,  cold  applications  to  the  abdomen,  cold 
sitz-baths  and  douches,  in  fact  hydropathy :  these  are  the  resolvents 
usually  indicated  associated  with  the  medicaments  just  referred  to  in 
the  treatment  of  chronic  ovaritis. 

III.  The  frequent  complications  which  exist  in  the  uterus,  the  co- 
existence of  leucorrhoea,  ulceration  of  the  cervix  and  vulval  pruritus, 
require  treatment  suitable  for  these  various  morbid  states.  There  is 
one  more  indication  to  be  fulfilled,  viz.  to  facilitate  digestion,  relieve 
nervous  symptoms,  stimulate  nutrition  and  improve  the  condition  of 
the  blood  by  exercise,  generous  diet,  tonics,  iron,  and  hydropathy. 

Lastly,  if  an  abscess  has  formed  projecting  into  the  vagina  or 
rectum,  the  rapid  increase  of  which  may  cause  the  fear  of  its  opening 
in  an  unfavorable  direction,  after  having  made  an  exploratory/  puncture, 
the  pus  should  be  evacuated  by  the  vagina  and  detersive  or  slightly  irri- 
tant injections  made  into  the  centre.  When  the  abscess  points  towards 
the  abdominal  wall  it  should  be  opened  with  Yienna  paste  according 
to  the  method  employed  in  opening  abscesses  of  the  liver,  so  as  to 
prevent  the  effusion  of  pus  into  the  peritoneal  cavity  :  the  scar  is  in- 
cised and  excised  every  day,  in  order  to  apply  more  Yienna  paste  to 
the  wound  and  so  get  nearer  the  centre,  after  having  determined 
adhesions  in  the  neighbourhood. 

Faures^  describes  a  case  of  ovaritis  followed  by  suppuration,  in 
which  the  artificial  opening  of  the  abscess  above  the  crural  arch  was 
followed  by  cure.  I  have  lately  seen  a  similar  case,  and  another  in 
which,  after  numerous  applications  of  the  cautery  to  the  left  hypo- 
gastric and  iliac  regions,  the  abscess  opened  spontaneously  near  the 
linea  alba;  the  patient  was  cured. 

2.  Inflammation  of  the  Fallopian  Tube 

Salpingitis  (inflammation  of  the  Fallopian  tube),  hardly  mentioned 
by  West  (1858)  and  Nonat,  is  described  by  Scanzoni,  Aran  and 
Becquerel. 

Inflammation  is  easily  developed  in  the  Fallopian  tube,  on  account 
of  the  continuity  of  this  canal  with  the  peritoneum  on  the  one  hand, 
and  with  the  uterine  mucous  membrane  on  the  other;  but  it  rarely 
occurs  unaccompanied  by  ovaritis  or  pelvi-peritonitis.  Usually  there 
is  simultaneous  inflammation  of  the  Fallopian  tube  and  ovary,  this 
double  inflammation  being  very  similar  to  peri-uteriue  inflammation. 
When  salpingitis  exists  alone  it  may  pass  unobserved  :  lesions  charac- 
terising it  are  met  with  in  women  who  have  never  complained,  and 
yet,  according  to  statistics,  diseases  of  the  oviducts  alone  are  more 
frequent  than  those  of  the  ovaries  alone.  Scanzoni^  thinks  that 
inflammation  of  the  Fallopian  tube,  and  especially  inflammation  of  its 
mucous  membrane,  which  he  calls  catarrh,  almost  always  accompany 
an  analogous  affection  of  the  mucous  membrane  of  the  uterus  or 
vagina.     Salpingitis  is  often  double.      It  exists  simultaneously  or  suc- 

■^  Gazette  hebdomad.,  v,  547. 
^  Op.  cit.,  p.  86-5,  et  seq. 


OVARITIS    AND    SALPINGITIS 


527 


cessivelj  on  both  sides.  It  may  be  either  acute  or  chronic.  In  acute 
inflammation  the  Fallopian  tube  becomes  entirely  or  partially  fixed  and 
adherent  to  the  neighbouring  organs,  is  still  more  flexuous  than 
normally,  is  distended  by  fluid  and  tumefied ;  the  walls  become  thick, 
soft,  dark  red  in  colour,  with  or  without  vascular  arborisation.  The 
fringes  of  the  fimbriated  extremity  which  are  reddish,  infiltrated  and 
sometimes  adherent  to  the  neighbouring  organs,  are  usually  bent  down 
and  applied  to  one  of  the  organs  to  which  they  adhere.  The  mucous 
membrane  is  red,  swollen,  moistened  with  a  fluid  composed  chiefly  of 
epithelial  cells  and  sometimes  of  pus.  When  the  fimbriated  extremity 
is  obliterated,  especially  if  the  ostium  ulerinum  is  so  also,  there  is  an 


Fig.  .316. — Fallopian  tubes  thickened  by  inflammation  and  distended  by  a  col- 
lection of  fluid  (after  Hooper,  The  Morbid  Anatomy  of  the  Human  Uterus 
and  its  Appendages,  with  Illustrations  of  its  Organic  Diseases,  pi.  in -4. 
London,  1832). 

accumulation  of  fluid  distending  the  cavity  of  the  Fallopian  tube.  It 
is  exceptional  to  see  these  morbid  products  discharged  into  the  peri- 
toneum,^ and  when  peritonitis  is  developed  it  is  usually  due,  not  to  an 
effusion,  but  to  the  propagation  of  inflammation  by  continuity  of 
tissue. 

In  chronic  inflammation  the  Fallopian  tube  is  two  or  three  times 
the  size  of  the  organ  normally,  in  colour  it  is  slaty  grey,  the  walls  are 
4  or  5  millimetres  in  thickness,  of  firm  consistency,  almost  obliterat- 
ing the  cavity  in  which  pus  is  not  accumulated  unless  there  are  adhe- 
sions;  the  mucous  membrane  is  greyish,  thickened  and  resistant. 

'  Puech  has  published  a  remarkable  case  of  this  kind  {Gazette  des  hupitaux, 
1860.  pp.  517  and  522). 


528  UTERINE   DISEASES  IN    DETAIL 

Salpingitis  may  be  complicated  by  inflammation  of  the  uterine 
mucous  membrane,  by  obliterations  from  adhesions  formed  with  the 
neighbouring  parts,  or  by  the  fringes  of  the  fimbriated  extremity 
adhering  together,  and  by  the  accumulation  in  its  cavity  of  a  serous 
or  sero- mucous  fluid  incorrectly  called  dropsy.  The  usual  seat  of  this 
dropsy  is  the  abdominal  extremity  of  the  tubes.  Scanzoni  says  that 
they  may  be  folded  back  at  several  points,  divided  into  five,  six,  or 
even  a  larger  number  of  sacs  of  various  sizes,  resulting  from  as  many 
obliterations  of  the  canal.  He  has  seen  one  of  these  tumours  equal 
in  size  the  head  of  a  child  of  ten  years ;  but  they  do  not  generally 
exceed  the  size  of  the  fist.  At  other  times  external  adhesions  close 
the  tube  and  there  may  be  dropsy  without  inflammation ;  sometimes 
the  fluid  is  contained  in  a  cyst  of  the  tube  or  in  multiple  cysts  which 
do  not  communicate  with  each  other. 

A  considerable  number  of  cases  are  recorded  in  which  the  fluid 
contained  in  the  tube  appears  to  have  made  a  way  for  itself  through 
the  uterus  or  vagina. 

Although  this  profluent  dropsy  of  the  tubes  as  Eokitansky  calls  it 
has  been  proved  to  exist,  Kiwisch  observes  that  the  same  symptoms 
may  result  from  the  perforation  of  an  ovarian  cyst  or  from  hydrorrhoea 
of  the  uterusj  and  that  it  is  surprising  that  a  discharge  from  the 
abdominal  extremity  of  the  tubes  into  the  peritoneal  cavity  has  not 
been  observed,  since  it  is  nearer  the  seat  of  the  dropsy.  In  such 
cases,  however,  this  extremity  is  often  obliterated,  and  Scanzoni,^  who 
mentions  these  objections,  gives  the  details  of  an  autopsy  proving  the 
possibility  of  such  discharges  by  the  uterine  extremity  of  the  tubes 
into  the  womb  and  vagina.     These  cases,  however,  are  very  rare. 

The  causes  of  salpingitis  are  uncertain ;  abortion,  delivery,  previous 
inflammation  of  the  uterus  seem  to  determine  it.  It  may  possibly 
result  from  ovaritis,  pelvic  peritonitis,  or  even  be  idiopathic,  but  more 
frequently  it  is  propagated  from  acute  endometritis. 

hiagnosis. — There  is  the  same  uncertainty  with  regard  to  the  dia- 
gnosis. Acute  inflammation  may  be  confounded  with  ovaritis,  metri- 
tis (especially  when  internal)  pelvic  or  generalised  peritonitis;  chronic 
inflammation  with  chronic  internal  metritis  which  is  often  concomitant. 
Kiwisch  gives  as  a  sign  of  inflammation  and  dropsy  of  the  tubes  the 
presence  of  elongated,  mammillated,  elastic  tumours  in  emaciated 
women  on  the  lateral  and  upper  portions  of  the  uterus  on  both  sides. 
1  agree  with  Aran  and  Scanzoni  that  this  sign  is  not  sufficient ;  for 
other  pelvic  organs,  multiple  adhesions,  the  ovaries,  the  inflamed  and 
tumefied  broad  ligments  may  be  taken  for  the  tubes.  In  the  case  of 
salpingitis  the  kind  of  mammillated,  undulating,  irregular  and  painful 
cord  formed  by  the  congested  tube,  is  perceived  higher  up  than  in  the 
case  of  phlegmon  of  the  broad  hgament :  it  is  attached  to  the  ovary 
and  uterus,  and  occupies  less  than  phlegmon  of  the  broad  ligament 
the  corresponding  side  of  the  pelvic  cavity.  It  is  not  uncommon  to 
observe  it  on  both  sides  simultaneously  or  successively,  the  inflamma- 
tion extending  from  the  uterus  to  the  tube,  to  the  ovary  of  one  side, 

»  Op.  cit.,  p.  .367. 


OVARITIS    AND    SALPINGITIS  529 

and  soon  afterwards,  at  a  monthly  period,  when  the  patient  is  thought 
to  be  cured,  it  reaches  the  tube  and  then  the  ovary  of  the  other  side. 
I  have  diagnosed  salpingitis  from  these  signs,  the  autopsy  proving 
that  I  was  correct.  In  order  to  be  certain,  we  must  be  able  to  recog- 
nise the  ovary  and  distinguish  it  from  the  diseased  tube,  which  is  very 
difficult  especially  in  the  pathological  state.  In  a  doubtful  case  the 
probability  is  in  favour  of  ovarian  disease,  as  the  latter  is  more  com- 
mon than  salpingitis.  Aran  describes  a  case  of  tubal  abscess  mis- 
taken by  himself  for  abscess  of  the  ovary.  Digital  touch  associated 
with  palpation  indicates  the  form  and  seat  of  the  inflammatory  tubal 
tumour.  A  bougie  might  be  introduced  into  the  tube  if  the  uterus 
had  been  previously  dilated  by  a  retentum.  Scanzoni  says  that  simple 
catarrh  of  the  tubes  (inflammation  of  the  mucous  membrane)  is  never, 
during  life,  accompanied  by  symptoms  allowing  of  its  being  diagnosed, 
and  frequently  dropsical  dilatations  of  the  tubes  have  persisted  for 
years,  without  presenting  any  morbid  phenomenon  of  importance.  My 
own  observations  have  convinced  me  that  this  malady  always  proceeds 
in  this  way  when  there  is  no  peritoneal  inflammation;  when  there  is, 
the  symptoms  are  very  marked,  especially  when  perforation  of  a  tubal 
abscess  is  the  cause  of  the  peritonitis.  Accumulations  of  pus  in  the 
tube,  real  abscesses,  which  Scanzoni  thinks  are  almost  always  con- 
nected with  the  puerperal  state,  expose  to  the  same  accidents  as 
ovarian  or  pelvic  abscesses.  Observation  has  proved  that  they  may 
open  into  the  rectum  (Scanzoni  relates  a  case),  vagina  or  peritoneum, 
and  that  in  the  latter  case  death  is  almost  inevitable.  Verjus  ^ 
describes  a  case;  fifteen  days  after  an  abortion  death  occurred  in  con- 
sequence of  an  abscess  of  the  left  tube  the  size  of  a  chestnut  having 
opened  into  the  peritoneum. 

Peritonitis  may  result  from  salpingitis  in  three  ways :  1 ,  by  the 
inflammation  being  propagated  from  the  fimbriated  extremity  to  the 
peritoneum;  2,  by  discharge  of  the  tubal  pus  through  the  gaping 
fimbriated  extremity ;  3,  by  perforation  of  the  tube.^  In  addition  to 
the  case  previously  mentioned  (527  note)  I  have  collected  three  other 
examples  of  perforation  of  tubal  abscess  into  the  peritoneum. 

Therefore  chronic  salpingitis,  like  chronic  ovaritis,  exposes  women 
who  suff'er  from  it  to  the  constant  danger  of  peritonitis  which  may 
break  out  on  the  slightest  cause,  the  most  insignificant  surgical  opera- 
tion on  the  uterus  causing  death  in  twenty-four  or  thirty-six  hours ; 
for  this  reason  the  physician  before  performing  any  operation  on  the 
uterus  ought  to  ascertain  that  there  is  no  inflammation  of  the  uterus, 
its  appendages,  or  the  pelvic  peritoneum. 

The  treatment  of  acute  salpingitis  is  the  same  as  that  of  perito- 
nitis, and  that  of  chronic  salpingitis  the  same  as  for  endometritis  and 
chronic  ovaritis. 

'  Theses  cle  Paris,  1844. 

^  Forster,  Wiener  vied.  Wochenschrift,  1859,  Nos.  44  and  45. 


34 


530.  UTERINE    DISEASES   IN   DETAIL 


3.  Inflammation  of  the  Fallopian  Tube  and  of  the  Ovary 

The  features  most  deserving  of  interest  in  these  cases  of  salpingitis 
and  ovaritis  are  the  coexistence  of  the  one  with  the  other,  or  the 
simultaneous  existence  of  oophoritis  or  salpingitis  on  both  sides,  or 
the  successive  development  of  inflammation  in  both  organs  alternately 
on  either  side.  This  propagation  of  uterine  inflammation  to  the  ovi- 
duct and  thence  to  the  ovary,  sometimes  on  one  side,  sometimes  on  the 
other,  is  certainly  one  of  the  most  singular  and  characteristic  features 
of  these  kinds  of  maladies.  It  probably  depends,  on  the  one  hand,  on 
the  organic  sympathy  connecting  the  various  parts  of  the  genital 
economy,  and  facilitating  the  development  of  these  inflammations,  so 
well  observed  by  Gosselin  apropos  of  perimetritis.  On  the  other  hand, 
it  depends  on  the  influence  which  a  diathetic  afi'ection  exercises  on  the 
development  of  inflammation  successively  on  the  various  points  of  the 
genital  economy  and  even  of  other  organs.  It  is  characteristic  of  dia- 
thetic afi'ections  to  prolong  their  duration  till  the  cause  of  the  malady 
has  been  extinguished  by  treatment,  and  to  provoke  manifold  simulta- 
neous or  successive  localisations  of  the  same  affection  on  several  organs 
or  several  tissues,  till  this  affection  has  been  exhausted  or  completely 
neutralised  by  general  treatment. 

In  syphilis,  and  even  in  venereal  affections  such  as  leucorrhoea,  I 
have  observed  the  propagation  of  the  malady  to  the  oviduct  and  to  the 
ovary.  In  herpetism  I  have  observed  the  same  thing  and  have  seen 
the  most  curious  cases  of  successive  or  alternating  localisations  on  the 
vagina,  uterus,  Fallopian  tube,  ovary  and  vice  versa,  on  one  side  or  the 
other,  or  on  both.  Rheumatic  inflammations  do  not  escape  this  law. 
But  the  most  curious  fact  of  all  is  that,  in  patients  in  whom  I  have 
been  unable  to  discover  any  other  symptom  of  a  diathetic  affection 
(owing  to  this  organic  sympathy  connecting  the  various  organs  of  the 
genital  economy  by  an  invisible  link) ,  I  have  seen  inflammation  just  as 
it  was  thought  to  be  extinguished  revive  in  the  most  unexpected  way, 
and  be  propagated  suddenly  to  the  Pallopian  tube  on  one  side  and  then 
to  the  ovary,  always  taking  advantage  of  the  monthly  congestion  as 
the  best  opportunity  for  these  unexpected  recurrences ;  then  again, 
when  we  had  reason  to  hope  that  its  action  was  exhausted  on  the  ovary, 
it  revived  in  the  uterus  at  another  monthly  period,  producing  metritis, 
differing  more  or  less  in  its  form  from  that  which  had  been  treated 
three  or  four  months  ago ;  at  the  following  periods  this  metritis  was 
propagated  from  the  uterus  to  the  oviduct  of  the  other  side,  then  at  a 
later  period  to  the  ovary  of  the  same  side,  and  only  finally  exhausted 
after  all  parts  of  the  internal  genital  economy  had  been  attacked  by 
inflammation,  sometimes  frequently.  I  have  seen  several  cases  of  this 
kind,  some  more  or  less  incomplete  with  regard  to  the  various  parts  of 
the  affected  ovaries  or  oviducts,  others  more  or  less  complete,  all  parts 
of  the  ovaries  and  tubes  having  been  affected  successively,  some  even 
repeatedly,  as  if  the  remains  of  the  inflammatory  congestion  furnished 


PERI-UTERINE    INFLAMMATION  531 

materials  for  the  revival  of  the  former  inflammation,  or  for  the  develop- 
ment of  a  new  inflammation. 

I  remember  a  patient  who  came  from  Algiers  to  consult  me  for 
chronic  metritis,  from  which  she  had  suffered  for  several  years,  in 
whom  this  propagation  occurred;  the  various  parts  of  the  internal 
genital  economy  being  alternately  and  successively  affected  right  and 
left  without  any  apparent  cause  and  lasting  for  eight  months.  In  such 
a  case  it  would  have  been  most  dangerous  to  have  cauterised  the  cavity 
of  the  body. 

In  such  patients,  I  have  profited  by  the  displacement  of  the  inflam- 
mation, to  discover  the  symptoms  which  pain  and  tumefaction  of  tube  or 
ovary  determine.  The  difference  between  the  symptoms  of  salpingitis 
and  those  of  ovaritis  are  easily  recognised  when  we  have  the  opportunity 
of  observing  them  from  month  to  month,  sometimes  incompletely  de- 
veloped, sometimes  at  the  summit  of  their  intensity,  now  on  one  side,  now 
on  the  other,  now  on  both  simultaneously,  alone,  or  associated  with  those 
of  pelvic  peritonitis,  cellulitis,  phlegmon  of  the  broad  ligaments,  &c.  Such 
cases  help  to  dissipate  the  obscurity  which  in  other  circumstances  may 
conceal  the  real  signs  on  which  we  have  based  the  diagnosis  of  salpin- 
gitis and  ovaritis.  It  is  only  after  having  had  the  opportunity  of 
observing  them  and  submitting  them  to  rigorous  analysis  that  we 
have  been  able  to  arrange  the  elements  of  this  diagnosis  in  descriptions 
representing  the  various  aspects  which  these  maladies  assume. 

The  diagnosis  and  treatment  of  this  disease  is  the  same  as  for  peri- 
uterine inflammation,  which  it  produces  easily,  as  I  shall  now  have 
occasion  to  show. 

Peri-uterine  Inflammation 

I  willingly  retain  this  expression  adopted  in  the  previous  editions  of 
this  work  to  designate  the  malady  described  till  lately  by  surgeons 
under  the  name  oi  pelvic  abscess,  which  only  describes  one  of  its  ter- 
minations, and  by  contemporary  gynsecologists  as  pelvic  cellulitis 
(Gendrin),  peri-uterine  phlegmon,  peri-uterine  engorgement  (Nonat), 
inflammation  of  the  annexes,  phlegmon  of  the  broad  ligaments  (Henry 
Bennet),  perimetritis  (Scanzoni),  pelvic  peritonitis  (Burnutz  and 
Goupil),  names  which  recal  not  only  the  ideas  which  these  various 
practitioners  had  as  to  the  seat  of  the  malady,^  but  also  the  inflamma- 
tions which  may  attack  the  various  tissues  and  various  regions  round 
the  uterus.  Matthews  Duncan^  has  proposed  the  name  oi perimetritis 
for  inflammation  of  the  peritoneum  surrounding  the  uterus  smd  para- 
metritis for  that  of  the  cellular  tissue  in  connection  with  the  uterus. 
The  expression  peri- uterine  inflammation  is  more  correct  because  more 
vague,  including  all  the  others  without  prejudging  anything  as  to  the 
seat  of  the  malady.  Now,  this  seat  may  vary,  the  disease  attacking 
one  or  other  of  the  organs  subject  to  it,  or  all  at  once. 

I  In  Germany  it  is  described  under  the  name  of  jjeri-ocip/i-onfis,  or  peri- 
salpingitis, according  to  whether  the  ovary  or  tube  has  been  the  starting  point. 
^  A  Practical  Treatise  oyi  Perimetritis  and  Parametritis.    Edinburgli,  1869. 


532  UTERINE    DISExiSES  IN    DETAIL 

Seat  and  pathological  anatomy. — I  shall  describe  cellulitisj  perito- 
nitis and  adenitis.  1.  Peri-uterine  cellulitis  and  pelvic  cellulitis.  I 
do  not  think  pelvic  cellulitis  can  be  denied.  I  shall  not  content 
myself  with  simply  stating  that  I  have  seen  it,  and  that  Nonat 
thought  that  all  peri-uterine  inflammation  might  be  included  under 
the  head  of  peri-uterine  phlegmon,  but  I  shall  refer  to  the  chief 
observations  which  have  been  made  on  it  recently.  Gosselin  has 
described  cases  of  peri-uterine  phlegmon.  Gallard  ^  has  devoted  his 
inaugural  thesis  to  the  description  of  this  malady.  Aran  has  seen  the 
two  peritoneal  folds  of  the  broad  ligament  separated  from  each  other 
by  a  thick  layer  of  pus :  three  times  partial  engorgements  of  cellular 
tissue,  diagnosed  during  life,  have  been  verified  after  death  in  two 
newly-delivered  women  (infiltration  of  blood  and  pus),  and  in  an  old 
woman  (fibro-plastic  indurations)  ;  in  another  puerperal  woman,  with 
internal  uterine  gangrene,  there  were  found  plastic  lymph  and  serosity 
in  the  recto-  and  vesico-vaginal  septa  and  in  all  the  pelvic  cellular 
tissue.  Peri-uterine  cellulitis  is  accepted  by  English  surgeons  as  well 
as  by  the  German  school.  Graily  Hewitt  ^  summing  up  the  ideas  of 
his  countrymen  on  this  point  says :  inflammation,  swelling,  and  the 
formation  of  pus  in  a  large  number  of  cases  certainly  originate  in  the 
connective  tissue  surrounding  the  uterus.  This  tissue  becomes  the 
seat  of  oedema  or  of  infiltration  of  fluids.  West,^  whose  remarks  on 
pelvic  abscesses  are  very  instructive,  agrees  with  Pirogoff  that  this 
state  is  correctly  designated  by  the  expression  acute  purulent  oedema. 
Virchow  ^  has  lately  published  the  results  of  the  investigations  he  has 
made  on  this  subject :  the  cellular  tissue,  according  to  him,  becomes 
at  first  tumefied,  thickened,  hardened  and  oedematous,  a  fluid  being 
discharged  from  it  when  it  is  incised.  Although  not  so  frequent  as 
Nonat  supposes,  peri-uterine  cellulitis  has  been  long  known.^  Nume- 
rous cases  have  been  recorded  of  phlegmons  of  the  broad  hgaments, 
especially  in  the  puerperal  state,  developed  and  propagated  to  a  greater 
or  less  extent  in  the  surrounding  cellular  tissue,  and  even  turning  into 
an  abscess  without  causing  an  attack  of  peritonitis.  I  have  seen  a 
phlegmon  of  the  right  broad  ligament  open  into  the  rectum,  another 
of  the  left  ligament  into  the  vagina,  without  having  given  rise  to  any 
symptom  of  peritonitis ;  in  three  patients  I  have  seen  indurations  and 
cicatricial  bands,  causing  a  lateral  and  persistent  displacement  of  the 
uterus,  twice  to  the  right,  once  to  the  left,  with  a  slight  obliquity  in 

^  De  V inflammation  du  tissu  cellulaire  qui  entoure  la  matrice,  &c.  Paris, 
1855. 

^  The  Diagnosis  and  Treatment  of  Diseases  of  Women,  p.  227.  London, 
1863. 

3  Op.  cit.,  p.  432. 

*  Virchoio's  Archiv,  1862,  Bd.  sxiii,  S.  415. 

^  Grisolle,  Des  Abces  de  la  fosse  iliaque,  in  Archiv.  gener.  de  medecine, 
1839,  and  Pathologie  interne,  8«  edit.,  1862,  t.  i,  p.  598.— Marchal  de  Calvi, 
Bes  Abces  phlegmoneux  intra-j)dviens,  these  pour  I'agregation.  Paris,  1844. — 
Behier,  Clinique  medicale,  1864. — Briand,  Thhse  de  Paris,  1866. — Trousseau, 
Des  Inflammations  ijeri-hysteriques,  Clinique  medicale,  t.  ii,  p.  747.  Paris, 
2  edit.,  1865. — Frarier,  Mtudes  siir  le  'plilegtiion  des  ligaments  larges,  These 
de  Paris,  1866. — Guichard-Choisitj,  These  de  Paris,  1862. 


PBEI-UTERINE    INFLAMMATION  533 

two  cases,  maladies  of  eight,  ten  and  twelve  years"  standing  in  which  the 
CO -existence  of  pelvic  peritonitis  could  not  be  presumed  at  any  period. 
The  correctness  of  this  diagnosis  was  confirmed  more  than  once  by 
autopsy. 

Frarier  describes  a  case^  of  suppurating  plegmon  of  the  right  broad 
ligament  after  confinement  which  opened  into  the  bladder :  the  autopsy 
proved  that  the  peritoneum  and  the  intestines  did  not  participate  in 
the  inflammation.  Behier  has  published  a  case^  of  suppurative 
phlegmon  of  the  left  broad  ligament,  occurring  two  days  after  a  first 
delivery,  extending  to  the  left  iliac  fossa,  without  alteration  of  the 
peritoneum  covering  it.     I  have  seen  an  equally  conclusive  case. 

There  are  also  examples  of  ante-uterine  and  retro- uterine  cellulitis 
without  any  symptom  of  peritonitis,  and  even  without  any  organic 
alteration  of  the  serous  membrane.  Simon^  has  published  a  case  of 
extra-peritoneal,  inter-utero-vesical  abscess,  occurring  in  the  course  of 
mahgnant  variola  amidst  symptoms  of  purulent  infection.  Alph. 
Guerin*  has  met  with  a  similar  abscess  resulting  from  direct  trauma- 
tism, from  the  ablation  of  a  polypus  situated  in  the  anterior  wall  of 
the  cervix,  Naudier  {Annates  de  GynScologie,  vi,  293)  has  described 
an  abscess  of  the  retro-uterine  cellular  tissue  in  a  woman  who  had 
hypertrophic  elongation  of  the  neck ;  the  abscess,  which  was  evacuated 
through  the  anterior  wall  of  the  rectum,  extended  behind  the  whole  of 
the  vagina,  the  whole  posterior  surface  of  the  uterus  and  laterally  to 
the  interior  border  of  the  left  ovary ;  pelvic  peritonitis  had  only  slowly 
followed  the  formation  and  evacuation  of  this  abscess  ;  the  annexes  of 
the  uterus  and  the  parts  surrounding  Douglases  space  could  not  be 
considered  as  the  starting-point  of  this  retro- uterine  cellulitis :  the 
case  proves  these  two  points.  I  have  seen  an  abscess  formed  between 
the  cervix  and  the  bladder  projecting  towards  the  vagina  and  opening 
into  the  bladder^  where  it  discharged  pus  for  a  long  time,  causing 
attacks  of  pain  from  time  to  time.  I  have  also  seen  an  abscess  deve- 
loped rapidly  behind  the  neck  of  a  prolapsed  uterus  in  a  patient  who 
had  been  imprudent  enough  to  go  out  the  day  after  leeches  had  been 
applied  to  the  cervix ;  it  opened  into  the  rectum  on  the  fourteenth  day, 
was  discharged  at  once  and  was  cured  in  three  weeks.  In  neither  of 
these  cases  were  there  any  symptoms  of  peritonitis. 

It  is  therefore  evident,  not  only  that  the  cellular  tissue  of  the  broad 
ligaments  may  become  inflamed,  especially  in  the  puerperal  state, 
without  the  peritoneum  participating  in  this  phlegmasia  \  but  also  that 
inflammation  of  this  tissue  which  usually  extends  laterally  (internal 
iliac  fossa,  cervical  arch,  abdominal  wall)  may  be  propagated  towards 
the  centre,  round  the  cervix ;  and  further,  that  the  inflammation  may 
even,  in  very  rare  cases,  be  developed  primarily  in  the  cellular  tissue 
loosely  connecting  the  cervix  with  the  peritoneum. 

PJdegmon  of  the  t)road  tigameuis  (including  parametritis)  may  con- 

'  Gazette  hebdomadaire,  t.  ix,  p.  82. 

^  Cliniqioe  medicate,  Obs.  38. 

3  Bulletin  de  la  Societe  anatomique,  1858. 

■•  Bulletin  de  la  Societe  de  chirurgie,  1866. 


534  UTEEINE    DISEASES    IN   DETAIL 

sist  in  a  simple  gelatinous  infiltration  of  these  organs,  cellulitis  being 
arrested  at  the  first  stage;  an  induration  remains  the  resolution  of 
which  occurs  afterwards,  gradually  diminishing  the  size;  most  fre- 
quently the  inflammation  pursues  its  course,  becoming  acute,  and  an 
abscess  is  formed ;  these  phenomena  rarely  occur  without  pelvic  perito- 
nitis being  produced  simultaneously.  Phlebitis  is  a  frequent  compli- 
cation of  phlegmon  of  the  broad  ligaments.  Trousseau^  has  insisted 
on  this  point:  "Phlegmon  of  the  broad  ligament  occurs  in  newly- 
delivered  women  after  contusion  or  inflammation  of  the  uterus  and  its 
annexes.  After  suppuration  of  the  placental  surface,  phlebitis  and 
lymphangitis  occur.  An  incision  made  on  the  borders  of  the  uterus 
at  an  autopsy  reveals  small  abscesses  in  the  venous  tissue.  The  cellu- 
lar tissue  round  these  veins  is  cedematous,  and  if  patients  do  not 
succumb  to  purulent  infection  on  account  of  adhesive  phlebitis  below 
the  purulent  collection,  the  intra-venous  abscesses  will  most  frequently 
be  the  origin  of  abscesses  of  the  broad  hgament.  The  same  remark 
may  be  made  of  suppurative  lymphangitis.'^ 

According  to  the  same  writer  phlebitis  is  the  most  common  cause 
of  phlegmon  of  the  broad  ligaments ;  but  it  may  also  be  the  conse- 
quence of  it.  It  may  be  said  that  it  is  primary  in  puerperal  phleg- 
mons, consecutive  in  non-puerperal.  When  the  autopsy  shows  circum- 
scribed phlebitis,  obstructing  clots,  pus  existing  or  not  in  the  cellular 
tissue,  phlebitis  has  been  the  cause  of  the  phlegmon ;  when  it  shows 
pus  in  the  cellular  tissue,  traces  of  phlebitis,  absence  of  clots,  purulent 
infection,  phlebitis  has  been  the  result  of  the  phlegmon,  the  inflamma- 
tion having  commenced  in  the  cellular  tissue  of  the  organ. 

Pelvic  cellulitis  may  be  divided  like  pelvic  peritonitis  according  to 
whether  it  extends  over  the  whole  pelvis,  which  it  rarely  exceeds,  or 
whether  it  is  confined  to  one  region  :  sometimes  round  the  uterus  or 
along  one  of  its  surfaces,  or  round  its  cervix ;  sometimes,  on  the 
contrary,  as  far  as  possible  from  the  womb,  in  the  iliac  fossa ;  some- 
times in  the  broad  ligament,  either  in  all  its  extent  or  at  its  base,  or 
at  the  summit  in  its  three  folds  or  only  in  one.  Both  broad  ligaments 
are  seldom  inflamed  simultaneously.  The  inflammation  is  usually 
limited  to  one  of  these  organs,  i.e.  to  one  of  the  sides  of  the  genital 
economy. 

2.  Peri- uterine  peritonitis  and  pelvic  peritonitis. — Autopsies  have 
proved  that  more  or  less  extensive  inflammation  of  the  peritoneum  not 
only  frequently  complicates  the  inflammatory  tumours  of  which  I  have 
just  spoken,  but  also  in  great  part  constitutes  inflammatory  peri-uterine 
tumours ;  this  inflammation  may  be  simply  sero-adhesive  or  may 
become  sero-purulent ;  whatever  the  termination  may  be,  it  is  com- 
plicated by  numerous  adhesions  uniting  together  the  various  surfaces 
of  the  peritoneal  covering  of  the  pelvic  organs,  e.g.  the  annexes  to 
each  other  or  to  the  uterus,  or  to  the  neighbouring  organs,  contained 
also  in  the  pelvis,  the  intestinal  circumvolutions,  the  rectum,  bladder, 
&c.  :  the  more  adhesions  there  are  the  larger  the  tumour  appears.     It 

Glinique  medicale,  2^  edit.,  t.  iii,  p.  747.  Paris,  1865. 


PEEI-DTERINE    INFLAMMATION  635 

is  to  Bernutz  ^  that  we  owe  the  elucidation  of  this  important  point  in 
uterine  pathology.  He  has  proved  by  three  autopsies  that  the 
inflammatory  tumour  which,  during  life,  had  presented  characteristic 
signs  of  peri-uterine  phlegmons,  was  not  situated  in  the  pelvic  cellular 
tissue,  but  that  it  was  constituted  by  peritoneal  adhesions  uniting  the 
viscera  of  the  pelvis  together. 

Bernutz  and  Goupil  ^  have  not  been  content  with  proving  the  exist- 
ence of  pelvic  peritonitis,  but  have  denied  that  of  peri-uterine  phleg- 
mons, having  always  seen  partial  peritoneal  inflammations  in  peri- 
uterine inflammatory  tumours.  Moreover,  they  have  also  seen  in  this 
pelvic  peritonitis,  a  phlegmasia  of  the  peritoneum  by  propagation, 
having  as  starting-point  an  inflammation  of  the  internal  genital  organs 
of  woman,  just  as  we  see  inflammation  of  the  testicle  in  man  produce 
that  of  the  serous  membrane  covering  it.  Only,  if  there  is  an 
analogy  in  the  morbid  process  which  takes  place,  there  is  none  in  the 
consequences;  the  transmission  of  the  inflammation  existing  in  the 
uterus  to  the  neighbouring  peritoneum  provokes  a  plastic  exudation 
which  not  only  determines  numerous  sympathies  by  its  extent,  but 
also  gives  rise  to  the  production  of  adhesions  connecting  the  uterus 
with  neighbouring  organs  and  more  or  less  compromising  its  func- 
tions. In  this  way  tumours  are  developed  perceptible  to  vaginal 
touch  or  hypogastric  palpation,  formed  partly  of  fibrinous  exudations, 
and  partly  of  agglomerated  viscera.  Lastly,  according  to  the  same 
writers  this  inflammation  of  the  pelvic  peritoneum  which  is  always 
symptomatic,  arises  more  frequently  from  inflammation  of  the  ovaries 
and  tubes  than  of  the  uterus.  But  the  chief  symptoms  of  these  peri- 
uterine affections  belong  to  pelvic  peritonitis,  whilst  the  uterine  or 
tubo-ovarian  aff'ection,  although  the  most  important,  being  the  cause 
of  the  development  of  inflammation  of  the  pelvic  serous  membrane,  is 
only  indicated  by  obscure  symptoms,  at  least  in  the  present  state  of 
our  knowledge.  Pelvic  peritonitis,  however,  does  not  merely  dominate 
symptomatology,  so  as  to  allow  peri-uterine  inflammation  to  be  dis- 
tinguished from  isolated  inflammation  of  the  ovary  or  tube,  but  it 
dominates  therapeutics,  being  really  the  source  of  the  chief  indica- 
tions. It  is  what  seems  to  me  to  constitute  the  most  important 
practical  consequence  and  therefore  the  chief  interest  of  the  valuable 
investigations  of  Bernutz  and  Goupil. 

Aran  ^  went  further  than  Bernutz  and  Goupil  in  reference  to  the 
subordinate  place  he  gave  to  pelvic  peritonitis  beside  ovaritis  and  sal- 
pingitis. He  considers  partial  peritonitis  only  secondary.  The  true 
element  of  peri-uterine  inflammation  is  alteration  of  the  uterine 
appendages,  ovary  and  tube,  constituting  an  inflammatory  centre, 
small  in  proportion  to  the  tumour  formed  round  this  focus  by  the 
pelvic  organs  including  the  intestines  adhering  together.  It  is  prob- 
ably always  from  the  ovary  or  tube  that  the  inflammation  first  arises. 

^  ArcMv.  gener.  de  medecine,  1857. 

'  Glinique  medicale  sur  les  maladies  des  femmes,  t.  ii,  premier  memoire  : 
De  la  pelvi-peritonite  et  de  ses  diverscs  varietes.  Paris,  1862. 
3  Op.  cit.,  p.  667. 


536 


UTERINE    DISEASES  IN    DETAIL 


After  acute  pelvic  peritonitis,  especially  when  this  is  puerperal,  in 
addition  to  the  characteristic  alterations  of  ordinary  peritonitis  we  find 
in  the  pelvic  cavity,  below  the  intestinal  circumvolutions  which  adhere 
loosely  together  and  to  the  neighbouring  organs,  a  globular  tumour 
as  large  as  a  hen's  egg,  attached  to  the  uterus,  from  which  it  may  or 
may  not  be  separated  by  a  groove,  sometimes  confounded  with  this 
organ,  which  it  is  difficult  to  recognise.  The  displaced  uterus  is  drawn 
towards  and  attached  to  the  tumour  or  pushed  back  in  a  contrary 
direction,  according  to  the  seat  of  the  tumour.  This  tumour  is  formed 
of  thick  false  membranes  hollowed  out  here  and  there  into  cavities, 
containing  a  citrine,  purulent  serosity  or  pus ;  above  them,  the  in- 
flamed peritoneum  is  seen  and  a  serous  infiltration  of  the  sub-peri- 
toneal cellular  tissue ;  in  the  centre  of  the  tumour  we  find  the  ovary 
and  tube  inflamed,  as  well  as  the  broad  ligament,  the  peritoneum  of 
which  is  injected  and  the  cellular  tissue  infiltrated  with  sanguinolent 
serosity  and  pus.  The  ovary  and  tube  being  prolapsed,  the  tumour 
often  rests  on  the  pelvic  floor.  The  purulent  collections  contained  in 
the  cavities  with  tomentous  walls  which  are  formed  by  adhesions,  have 
frequently  been  mistaken  for  infiltrations  of  the  cellular  tissue  of  the 
pelvis.  Suppuration  of  the  pelvic  cellular  tissue,  however,  is  quite 
exceptional.     When  the  annexes  are  inflamed  on  both  sides  the  tumour 


Tig.  317. — Retro-uterine  and  tubal  tumours  held  back  bj  false  membranes  to 
the  ovaries,  uterus  and  adjacent  tissues,  the  result  of  peri-uterine  inflam- 
mation (after  Hooper).  Compare  this  woodcut  with  Fig.  1,  representing 
the  general  view  of  the  same  organs  in  their  normal  condition. 

is  enormous  and  surrounds  the  uterus  in  a  kind  of  ring.  In  the 
chronic  state,  the  false  membranes  in  place  of  being  soft,  whitish  or 
yellowish,  have  become  thick,  resistant,  grey  or  black,  forming  short 
bands  extending  from  the  annexes  and  from  the  uterus  to  the  neigh- 
bouring organs,  which  they  unite  together  enclosing  spaces  which  are 


PERI-UTERINE    INFLAMMATION  537 

empty,  or  which  contain  citrine  serosity  or  pus.  The  uterus  more  or 
less  inclined,  deviated  or  flexed,  tumefied,  but  seldom  atrophied,  is 
sometimes  affected  with  internal  inflammation.  The  alterations  of  the 
annexes  are  fully  developed :  the  tubes  contain  pus  or  a  more  or  less 
considerable  quantity  of  serosity  which  may  give  rise  to  the  degenera- 
tion incorrectly  called  tubal  dropsy ;  the  ovaries,  which  are  seldom 
atrophied,  usually  form  purulent  sacs,  the  envelope  of  which  resists 
laceration  or  rupture  for  a  long  time.  The  abscesses  which,  after 
pelvic  peritonitis,  open  into  the  peritoneum,  rectum,  vagina,  bladder  or 
externally,  are  generally  abscesses  of  the  ovary  or  tube,  less  frequently 
peritoneal  purulent  collections  encysted  by  the  adhesions  of  false  mem- 
branes. These  latter  are  discharged  usually  at  the  commencement, 
the  false  membranes  being  then  imperfectly  organised,  and  as  a  rule  are 
emptied  into  the  peritoneal  cavity  by  laceration  or  fissure.  The 
former  are  evacuated  by  the  rectum  or  vagina,  from  the  effect  of  ulce- 
ration, after  previous  adhesion  of  the  two  cavities,  between  which  a 
communication  is  set  up,  that  of  the  abscess  on  the  one  hand  and  of 
the  rectum  or  vagina  on  the  other.  The  opening  becomes  a  fistula,  esta- 
blishing a  permanent  communication  between  these  cavities,  and  even 
allowing  stercoraceous  matter  to  pass  from  the  rectum  into  the  cavity 
of  the  abscess.  In  this  way  pelvic  peritonitis  or  perimetritis  may  pass 
through  the  various  stages  of  adhesive,  sero-adhesive,  sero-eucysted, 
purulent  peri-metritis,  and  even  of  hsemorrhagiparous  pachy-peritonitis 
{see  p.  545). 

Lastly,  although  it  may  be  limited  to  one  side,  the  side  of  the 
diseased  ovary,  the  starting-point  of  the  inflammation  of  the  serous 
membrane,  peritonitis  is  often  propagated  to  the  other  side,  and 
seldom  is  limited  to  the  side  first  attacked  ;  usually  it  spreads  round  the 
uterus  surrounding  all  the  internal  genital  economy. 

3.  Peri- uterine  Adenitis  and  Angioleucitis. —  Peri-uterine  cellu- 
litis and  pelvic  peritonitis,  with  all  their  varieties,  are  the  only 
maladies  included  by  gynsecologists  under  the  common  name  of 
peri-uterine  inflammation.  For  several  years  I  have  taught  in  my 
lectures  that  a  third  inflammatory  malady  exists,  which  ought  to 
be  included  in  the  peri-uterine  inflammations;  it  is  adenitis  and 
peri-uterine  angioleucitis,  which  is  often  acute  and  the  prognosis 
of  which  is  very  serious  when  it  is  puerperal  ;  more  frequently 
it  is  chronic  and  is  then  less  important  in  itself  than  from  the 
ulceration  of  the  uterine  mucous  membrane  of  which  it  is  the  certain 
sign. 

In  fatal  puerperal  inflammation  pus  is  not  found  in  the  veins. 
Although,  however,  inflammation  of  the  veins  is  exceptional  even  in 
puerperal  affections,  that  of  the  lymphatics  is  common,  as  was  proved 
by  the  autopsies  made  by  Champioimiere,  Leopold  and  others.  In 
puerperal  metritis,  inflammation  may  attack  the  lymphatics  more  vio- 
lently, so  that  after  death  the  latter  may  be  found  filled  with  pus,  not 
only  below  the  mucous  and  serous  membranes  of  the  uterus  and  in  the 
thickness  of  the  organ,  but  also  in  some  points  corresponding  especially 
with  the  posterior  region  of  the  uterus  and    near  its  cervix,  where. 


538  UTERINE   DISEASES   IN   DETAIL 

according  to  Championniere,  may  be  found  ganglia  gorged  with  pus 
and  clusters  of  lymphatic  vessels  distended  with  this  fluid,  which  may 
be  mistaken  for  suppurated  ganglia,  not  only  on  the  dead  body,  but 
even  during  life,  causing  errors  of  diagnosis. 

In  other  circumstances,  and  in  the  non-puerperal  state,  adenitis 
and  angioleucitis  may  present  themselves  in  the  acute  form  in  the 
same  organs,  the  inflammation  either  being  developed  under  the  in- 
fluence of  traumatic  causes  and  especially  of  acute  metritis  or  ovaritis, 
or  it  may  have  originated  from  acute  peri-uterine  inflammation,  in  the 
participation  of  which  the  ganglia  and  lymphatic  vessels  do  not  escape, 
and  in  which  the  adenitis  and  angioleucitis  developed  in  such  con- 
ditions survive  for  a  longer  or  shorter  time,  varying  in  intensity  and 
duration. 

In  other  circumstances  again  and  more  frequently,  angioleucitis  and 
adenitis  especially  occur  in  the  chronic  form  and  are  all  the  more  in- 
teresting to  describe,  as  they  appear  to  have  almost  escaped  observation 
till  now.  After  having  made  a  careful  vaginal  examination,  especially 
posteriorly  and  laterally,  as  well  as  at  the  base  of  the  broad  liga- 
ments, I  have  often  found  behind  and  to  the  sides  of  the  uterus, 
usually  to  the  right,  sometimes  at  one  point  only,  small  rounded 
tumours,  a  little  indented,  smooth  at  certain  points,  irregular  at  others, 
the  form,  hardness,  mobility  and  sensitiveness  of  which  contrast 
strikingly  with  the  characters  of  softness,  insensibility,  &c.,  of  the 
surrounding  tissues.  These  small  tumours  of  various  sizes  are  less 
voluminous  even  than  the  ovaries,  even  when  the  latter  are  not  en- 
larged by  inflammation,  and  are  usually  less  painful  than  these  organs, 
though  sometimes,  on  the  contrary,  they  are  excessively  so,  less  mobile 
also,  and  appear  to  be  connected  loosely  with  the  uterus,  the  vaginal 
cul-de-sac,  and  especially  with  the  innermost  layer  extending  above 
them. 

I  could  not  have  interpreted  the  tumours  just  described  otherwise 
than  as  remnants  of  inflammatory  indurations  or  as  adenitis  and 
angioleucitis,  i.e.  tumours  formed  by  clusters  of  vessels,  or  lymphatic 
ganglia  tumefied  and  rendered  painful  by  inflammation,  even  if  an 
autopsy  had  not  allowed  me  on  one  occasion  to  verify  my  suppositions 
in  a  woman  of  forty,  who  I  knew  had  suffered  for  long  from  leucor- 
rhcea  and  ulcerous  endometritis,  and  who  was  carried  off  by  pleuro- 
pneumonia, in  whom  I  found  adenitis  and  its  usual  cause  (chronic 
ulceration  of  the  mucous  membrane);  autopsies  also  on  newly 
delivered  women  who  had  succumbed  to  puerperal  disease  and  in 
whom  suppurative  adenitis  was  found  occupying  the  same  regions,  in 
like  manner  justified  my  opinion.  In  presence  of  such  symptomatic 
and  microscopic  proof,  hesitation  is  no  longer  possible.  I  observed 
this  retro-uterine  adenitis  in  patients  who  had  for  long  suffered  from 
some  affection  of  the  internal  genital  organs,  vaginal  and  uterine 
leucorrhoea,  or  from  long  existing  ulceration  of  the  cervix  which  still 
existed  on  the  mucous  membrane  of  the  cavities.  These  patients 
came  to  consult  me  because  they  had  been  treated  for  a  long  time  by 
their  own  doctors,  who  now  assured  them  that  they  were  cured ;  and 


PEEI-UTEEINE    INFLAMMATION  539 

they  were  cured  except  in  the  uterine  cavities  :  the  sound,  the  passage 
of  which  was  often  painful,  brought  back  pus  or  leucorrhcea,  some- 
times a  Kttle  blood,  which  made  me  suspect  a  suppurating  ulcer 
situated  on  the  mucous  membrane  of  the  cervix  or  body,  another 
example  of  the  services  rendered  by  the  sound.  I  have  usually 
regarded  this  chronic  adenitis  as  well  as  cervical  and  other  forms  of 
adenitis  as  symptomatic  of  inflammatory  suppurative  action  on  one  of 
the  mucous  membranes  where  the  afferent  vessels  of  the  tumefied 
ganglia  had  their  absorbent  network.  From  this  point  of  view,  the 
verification  of  retro-  or  latero-uterine  adenitis  is  interesting  even  if 
only  as  a  symptom  of  a  chronic  suppurative  phlegmasia  the  seat  of 
which  is  easily  determined.  It  is  also  interesting  in  itself;  for  it  con- 
stitutes a  malady,  the  intensity,  extent,  and  progressive  tendency  of 
which  requires  great  attention. 

Apart  from  the  symptoms,  either  direct  or  sympathetic  of  the 
uterine  malady,  and  of  the  ulcer  which  has  caused  it,  peri-uterine 
adenitis  has  special  symptoms  characterising  it :  lumbar  or  lumbo- 
sacral pain,  sometimes  extending  to  the  anus ;  continuance  of  the 
pains  previously  experienced  by  the  patient  which  are  increased  by 
marital  intercourse  even  when  most  of  the  apparent  uterine  symptoms 
have  disappeared ;  pain  elicited  by  digital  touch,  especially  when 
pressure  is  exercised  by  the  finger  behind  the  uterus  and  laterally, 
and  when  an  attempt  is  made  to  depress  the  retro-  or  dextro-uterine 
cul-de-sac. 

Course. — Like  all  phlegmasias,  peri-uterine  inflammation  may  be 
ac2de  or  chronic.  The  term  super-acute  has  been  added  to  designate 
acuity  of  the  highest  degree,  and  that  of  sub-acute  to  mark  a  kind  of 
transition  between  the  acute  and  the  chronic  forms.  I  do  not  think 
it  necessary  to  multiply  divisions ;  but  I  maintain  the  marked  differ- 
ence, with  regard  to  causes,  symptoms  and  treatment  between  the 
acute  and  chronic  forms. 

It  has  also  been  proposed  to  distinguish  puerperal  from  non- 
puerperal peri-uterine  inflammation.  Marchal  de  Calvi^  and  H. 
Bennet  ^  attach  importance  to  this  distinction.  The  latter  says, 
that  the  puerperal  state,  which  may  be  said  to  extend  to  the 
fourth,  fifth,  or  even  sixth  week  after  delivery,  is  one  of  the  most 
dangerous  conditions.  So  long  as  it  lasts  all  inflammatory  affec- 
tions present  a  special  gravity  and  especially  those  of  the  organs 
which,  directly  or  indirectly,  have  participated  in  parturition.  If 
inflammation  occurs  in  the  ovaries  or  broad  ligaments  immediately 
after  delivery,  it  is  frequently  as  a  complication  of  metro-peritonitis 
and  as  merely  an  after  symptom  of  this  formidable  affection.  A 
number  of  writers  on  puerperal  fever  have  noticed  the  frequency  of 
suppuration  of  the  ovaries  and  broad  ligaments  in  cases  of  metro- 
peritonitis terminating  in  death.  But  even  when  the  broad  ligaments 
are  inflamed  several  weeks  after  delivery,  the  general  symptoms  are 
more  intense,  the  local  tumefaction  more  considerable,  and  the  inflam- 

'  Annales  de  la  chirurgiefr.  et  etr.,  July  and  August,  1844. 
^  Op.  cit.rp.  39. 


540  UTERINE    DISEASES   IN    DETAIL 

mation  presents  a  greater  tendency  to  extend  to  the  adjacent  tissues 
than  in  the  non-puerperal  form  of  the  affection.  It  is  also  much 
more  difficult  to  arrest  its  progress  ;  the  inflammatory  and  suppurative 
action  continues  to  extend  long  after  the  first  collection  is  evacuated, 
and  in  a  number  of  cases  it  gives  rise  to  adhesions  and  abdominal  per- 
forations. This  serious  form  is  quite  exceptional  in  the  non-puerperal 
state,  whilst  in  the  puerperal  it  is  so  common  that  till  now  it  has 
been  considered  as  the  only  one  under  which  the  affection  is 
manifested. 

I  share  Bennet's  opinion,  but  do  not  see  why  the  two  forms  should 
be  described  separately.  Peri-uterine  inflammation  may  arise  in  the 
puerperal  state  as  in  any  other ;  it  is  certainly  produced  oftener  in  the 
former  state ;  it  is  then  more  serious  and  has  a  more  rapid  course, 
terminating  often  in  suppuration.  But  its  coincidence  or  its  relations 
with  the  puerperal  state  do  not  change  its  character;  it  passes  fre- 
quently from  the  puerperal  or  post  puerperal  to  the  chronic  form,  and 
there  may  be  great  uncertainty  as  to  its  real  origin :  lastly,  it  is  dia- 
gnosed in  the  same  way,  and  the  indications  off'er  differences  of  degree 
rather  than  of  nature. 

Frequency. — Peri  uterine  inflammation  is  very  common  :  indeed  it 
forms  about  one  third  of  uterine  diseases.  It  is  very  difficult  to  make 
an  exact  calculation,  because  peri-uterine  inflammation  in  place  of 
occurring  alone  may  complicate  the  majority  of  uterine  diseases.  Aran 
thought  that  with  inflammation  of  the  uterus  (parenchymatous  and 
mucous)  it  forms  two  thirds  of  uterine  diseases.  It  is  certain  that  out 
of  100  women  there  will  be  55  with  peritoneal  adhesions  and  showing 
traces  more  or  less  intense  of  pelvic  peritonitis.  Of  this  number  there 
are  far  more  married  women  than  virgins  and  more  multiparse  than 
primiparse. 

Etiology. — Menstrual  disorders  and  their  causes  physical  and  moral, 
long-contmued  excitement  of  the  genital  organs,  pregnancy,  labour, 
extension  of  inflammation  of  the  uterus  or  its  annexes  to  the  neigh- 
bouring parts.  It  will  be  seen  that  the  causes  are  almost  the  same  for 
metritis,  perimetritis,  ovaritis,  &c.;  it  is  the  predisposition  which 
varies  and  determines  the  localisation.  But  this  etiology  may  acquire 
some  interest  from  a  little  more  precision.  Now  we  know  from  ob- 
servation and  statistics  that  peri-uterine  inflammation  is  common  espe- 
cially from  20  to  30,  which  is  not  surprising,  seeing  that  ovarian  and 
tubal  inflammation  are  also  common  at  this  age  and  are  usually  the 
starting-points  of  pelvic  peritonitis.  Another  interesting  result  is  that 
about  two  thirds  of  these  diseases  are  the  consequences  of  labour, 
abortion,  and  consecutive  inflammation :  West  thinks  that  labour, 
abortion  and  consecutive  inflammation  enter  into  the  etiology  of  peri- 
uterine inflammations  at  the  ratio  of  77  per  cent. ;  Gallardand  Bernutz 
reduce  this  influence  to  45  or  44  per  cent.,  which  gives  an  average  of 
60  per  cent,  between  the  two  extremes,  which  is  very  nearly  the  pro- 
portion of  the  number  of  cases  (55  per  cent.)  in  which  Aran  found 
peritoneal  adhesions  and  traces  of  pelvic  peritonitis.  This  cause  of  peri- 
uterine inflammation  may  sometimes  be  ignored  because  symptoms  are 


PERI-UTERINE    INFLAMMATION  541 

not  always  developed  immediately  after  delivery,  sometimes  only 
appearing  much  later;  but  in  taking  care  to  trace  the  morbid  mani- 
festations to  their  source  we  discover  the  frequency  and  importance  of 
this  cause.  It  is  probable  that  the  operations  necessitated  by  difficult 
labour  and  the  imprudence  often  committed  by  newly-delivered  women 
in  resuming  marital  intercourse  and  their  ordinary  work  too  soon  have 
a  considerable  share  in  the  development  of  perimetritis.  Often,  how- 
ever, these  are  not  the  causes  of  the  malady.  ChurchilP  has  given  a 
good  description  of  the  various  ways  in  which  peri-uterine  inflamma- 
tion may  commence.  I  agree  with  Aran  that  very  often  there  is  either 
a  latent  morbid  state  or  a  morbid  predisposition  existing  before  de- 
livery, labour  being  only  the  determining  cause. 

Menstrual  disorders  which  may  be  placed  in  the  second  rank  as 
causes,  in  the  proportion  of  20  per  cent,  according  to  Bernutz  and 
Goupil,  in  that  of  9  or  10  per  cent,  according  to  Aran,  are  frequently 
only  symptoms  of  uterine  inflammation  already  existing,  of  a  previous 
latent  morbid  action,  which  has  necessarily  caused  either  dysmenor- 
rhoea  or  menorrhagia. 

The  same  remark  is  applicable  to  leucorrhoea  and  blenorrhagia  which 
may  also  become  causes  of  pelvic  peritonitis,  especially  in  women  who 
have  had  diseases  of  the  annexes,  mechanical  influences  having  their 
share  also.  Bernutz  attributes  a  great  deal  to  blenorrhagia  after  the 
third  week  and  more  as  the  monthly  period  approaches,  in  the  propor- 
tion indeed  of  29  per  cent.,  whilst  West  and  Aran  reduce  this  propor- 
tion to  1  or  2  per  cent.,  and  I  think  certainly  that  it  has  been 
exaggerated  by  Bernutz. 

The  neighbouring  inflammations,  those  of  the  rectum  or  intestines, 
dysentery,  metritis  especially,  the  persistence  of  ovaritis  and  salpingitis 
cause  the  development  of  perimetritis  and  determine  its  chronicity. 
Mechanical  influences  (cauterisation,  the  use  of  the  sound,  pessaries, 
injections)  have  not  apparently  a  greater  share  than  1  per  cent,  in  the 
etiology  of  peri-uterine  inflammation. 

Diagnosis — subjective  signs. — The  symptoms  of  peri-uterine  inflam- 
mation greatly  resemble  those  of  ovaritis  and  salpingitis,  but  there  is 
one  dominating  element  which  for  the  time  effaces  all  the  others  :  peri- 
tonitis or  pelvic  peritonitis. 

Acute  peri-uterine  inflammation  breaks  out  suddenly,  after  abortion 
or  delivery,  by  shivering,  heat,  perspiration,  nausea,  vomiting,  or  the 
appearance  of  fits  of  intermittent  fever  which  might  be  mistaken  for 
ague ;  or  it  may  be  preceded  for  days,  weeks  or  even  months,  by 
vague  discomfort,  symptomatic  of  inflammation  of  the  appendages,  such 
as  loss  of  appetite,  diarrhoea,  constipation,  vague  and  dull  pains.  Then 
comes  the  pain  characteristic  of  perimetritis,  sometimes  limited  to 
one  point  of  an  iliac  fossa,  generally  more  diffuse,  occupying  a  portion 
of  the  belly,  very  acute  if  not  spontaneous  on  pressure  near  the  Fal- 
lopian ligament.  In  addition  to  pain  there  is  great  heat,  swelling, 
tension  of  the  lower  half  of  the  abdomen,  the  muscles  of  which  contract 
as  if  to  shelter  the  organs  underneath,  dorsal  decubitus,  alteration  of 
^  Dublin  Journal  of  Medicine,  xxiv,  1844. 


542  UTERINE   DISEASES   IN   DETAIL 

the  features,  small  coucentrated  pulse,  bilious  vomiting  in  some  cases, 
just  as  in  simple  peritonitis.  When  these  symptoms  are  alleviated 
there  remains  a  feeling  of  fulness,  discomfort,  pain  in  the  hypogas- 
trium,  especially  on  one  side,  exacerbations  of  pain,  slight  fever,  in- 
creased in  the  evening,  anorexia,  &c.  The  description  of  the  symptoms 
of  pelvic  abscesses  following  delivery  which  may  be  regarded  as  typical 
is  generally  characteristic :  rigors,  more  or  less  intense  pain,  quick 
pulse  and  acute  fever  mark  the  commencement  of  inflammation.  But 
these  initial  symptoms  may  be  absent,  the  patient  becoming  gradually 
ill  without  the  appearance  of  acute  symptoms  of  any  kind.  It  is  not 
uncommon  to  see  a  woman  who  was  in  good  health  at  the  time  of  her 
confinement  experience  symptoms  of  general  indisposition  three  or  four 
weeks  afterwards,  become  gradually  weaker  and  thinner,  and  complain 
of  pain  down  the  legs  or  in  the  pelvis,  lose  her  appetite  and  power  of 
digestion  and  occasionally  have  shivering  fits ;  after  these  symptoms 
have  lasted  for  a  week  or  two  the  pelvic  symptoms  become  more 
marked,  such  as  difficult  and  painful  defsecation  and  micturition,  pain 
and  discomfort  in  the  pelvis,  &c.  This  pain  is  increased  by  the 
slightest  movement,  and  yet  the  real  cause  being  misunderstood,  it  is 
often  attributed  to  weakness.  The  presence,  however,  of  a  pelvic 
tumour  soon  discovers  to  the  physician  the  cause  of  all  these 
symptoms. 

Chronic  peri-uterine  inflammation  may  either  be  the  termination  of 
acute  inflammation  or  it  may  be  chronic  from  the  beginning,  which 
leads  to  many  errors  of  diagnosis.  A  subacute  condition  may  exist, 
an  intermediate  form,  presenting  the  same  phenomena  as  the  acute 
but  less  intense,  and  producing  hectic  fever  in  delicate  patients.  This 
form  is  not  uncommon  after  delivery ;  the  patient  rises,  but  she  is 
weak  and  complains  of  pain,  indigestion,  &c. ;  there  is  slight  feverish- 
ness  and  the  secretion  of  milk  is  irregular.  In  others  who  are 
stronger  the  inflammation  only  shows  itself  later,  but  it  originates 
from  labour.  This  uncertainty  as  to  the  origin  of  chronic  perimetritis 
seems  to  me  a  reason  for  rejecting  the  distinction  of  the  puerperal  and 
non-puerperal  varieties.  When  chronic  inflammation  is  developed  all 
at  once,  which  is  rare,  the  commencement  is  insidious.  It  only 
attracts  attention  when  the  tumour  has  become  large,  or  when  the 
pains  become  acute  and  when  functional  and  digestive  disorders  occur, 
which  happens  especially  during  menstruation.  In  fact,  chronic  peri- 
uterine inflammation  presents  few  marked  local  signs,  especially  if 
there  is  any  intercurrent  malady  such  as  tuberculisation.  General 
symptoms  occupy  the  first  place.  These  are :  weariness,  paleness, 
emaciation,  sallow  face,  eyes  without  expression,  dry  sometimes  hot 
skin,  weak,  small,  compressed  pulse,  frequently  oppression,  palpitation, 
headache,  neuralgia,  hysteria,  numbness  of  one  side  especially  of  the 
left,  tingling  of  the  extremities,  increased  or  diminished  sensibility, 
painful  points  along  the  spine,  dyspepsia,  acidity,  epigastric  swelling, 
occasionally  vomiting. 

On  interrogating  patients  we  generally  find  that  there  have  been 
acute  symptoms  of  some  kind  to  begin  with.     Since  then  in  spite  of 


PEEI-UTERINE   INFLAMMATION  543 

the  comparative  calm,  a  feeling  of  weight  and  discomfort  has  remained 
in  the  pelvis,  with  internal  heat  and  pulsation  increased  by  walking, 
fatigue  or  coitus.  Menstruation  is  suppressed  or  less  abundant 
(metrorrhagia  being  the  exception) ;  at  the  monthly  periods  the  pains 
are  more  acute  in  the  abdomen,  there  is  tumefaction  of  the  belly, 
nausea,  vomiting,  heat  of  the  skin,  shivering,  increased  leucorrhcea, 
vulval  irritation  and  desquamation,  loaded  urine,  painful  defecation, 
excretion  of  mucus  by  the  anus  or  diarrhoea.  Order  is  re-established 
till  a  new  crisis ;  but  there  is  still  weariness,  continuance  of  lumbar 
and  hypogastric  pain  radiating  in  one  or  both  limbs  to  the  knee  or 
even  to  the  foot ;  leucorrhcea ;  constipation  or  diarrhoea ;  vulval  itch- 
ing. On  resuming  work  or  coitus,  or  at  the  monthly  periods,  there 
are  exacerbations  as  in  ovaritis,  characterised  by  the  redouhlements 
inflammatoires  of  Gosselin,  and  causing  a  symptomatic  manifestation 
analogous  to  that  of  the  acute  period,  with  the  exception  of  the  general 
symptoms,  which  are  less  marked.  These  exacerbations  last  from 
three  to  eight  days ;  they  may  be  repeated  every  month  or  at  intervals 
of  three  months,  six  months  or  a  year.  They  aggravate  the  position 
of  patients  but  rarely  cause  death.  We  must  remember  that  the 
chronicity  and  inflammatory  attacks  depend  not  only  on  the  impru- 
dence of  patients  and  on  insufficient  care,  but  chiefly  on  the  persistence 
of  inflammation  of  the  ovary  and  Pallopian  tube.  At  every  fresh 
attack  peritonitis  appears ;  in  the  end,  however,  it  organises  a  boun- 
dary of  false  membranes  which  it  does  not  cross.  This  boundary  is  on 
the  level  of  the  brim,  iliac  fossae,  or  iliac  crests  (p.  553,  fig.  323)  : 
inflammation  of  the  serous  membrane  never  passes  beyond  the  level  of 
the  umbilicus.  Percussion  reveals  its  exact  limits :  all  the  inflamed 
part  gives  a  dull  sound,  while  the  portion  which  escapes  peritonitis 
gives  a  tympanitic  sound. 

Pain  during  the  development  of  acute  pelvic  peritonitis  or  an 
exacerbation  of  the  chronic  form  tends  to  become  generalised  whilst 
preserving  a  maximum  of  intensity  in  its  original  seat  as  in  ordinary 
peritonitis.  It  is  acute,  darting,  incessant  and  pulsating  with  exacer- 
bations every  three  or  four  hours,  especially  when  there  is  internal 
metritis,  leucorrhcea,  &c.,  and  with  tension  of  the  belly  which  cannot 
bear  any  pressure.  It  is  also  felt  in  the  vagina  and  rectum  preventing 
the  introduction  of  the  finger.  In  chronic  peri-uterine  inflammation 
this  pain  is  often  confounded  with  that  of  ovaritis,  metritis  and  even 
with  the  leucorrhcea  which  co-exists  with  it.  Like  the  disease  it  has 
various  seats  :  generally  occupying  one  side  of  the  belly,  especially  the 
left,  or  a  large  part  of  the  hypogastrium  with  a  maximum  of  intensity 
at  the  point  corresponding  to  the  tumour;  it  radiates  towards  the 
kidneys,  loins,  pelvis,  vulva,  thighs  and  legs,  especially  on  the  affected 
side;  it  is  fixed,  deep,  pulsating,  aggravated  by  walking,  fatigue, 
standing,  or  coitus ;  sometimes  it  is  acute  and  darting,  at  the  same 
time  becoming  mobile,  wandering,  intermittent,  in  which  case  it  is 
probably  due  to  neuralgia;  it  is  sometimes  hardly  apparent  unless 
elicited  artificially  by  touch,  abdominal  pressure,  a  fall,  coughing, 
vomiting,  constipation,  eff'orts  during  micturition  or  defecation,  walk- 


544  UTEEINE    DISEASES    IN    DETAIL 

mg,  the  presence  of  a  foreign  body  in  the  vagina,  the  heat  of  the  bed, 
uterine  congestion,  the  menstrual  period.  Sometimes  even  lying  down 
increases  it,  so  that  patients  instinctively  adopt  the  decubitus  which  is 
least  painful  to  them ;  this  is  generally  the  dorsal  with  slight  inclina- 
tion to  the  opposite  side  from  the  tumour.  The  heat  felt  by  patients 
in  acute  perimetritis  is  considerable ;  it  is  at  the  bottom  of  the  pelvis, 
becoming  sometimes  burning  in  the  vagina.  In  chronic  perimetritis  it 
is  hardly  observed  except  at  the  time  of  an  inflammatory  paroxysm. 
The  symptoms  of  neighbourhood  are  variable ;  there  is  constipation, 
discomfort  and  pain  on  going  to  stool  with  vesical  tenesmus.  Nonat 
says  that  in  acute  perimetritis  menstruation  is  usually  increased :  this 
is  not  my  experience,  nor  have  I  often  remarked  leucorrhoea  as  a 
result  of  inflammatory  reaction  on  the  uterine  mucous  membrane. 
What  is  more  frequently  observed  is  suppression  of  the  lochiee  in  the 
puerperal  state  and  the  extension  of  the  inflammation  to  the  uterine 
parenchyma. 

In  chronic  inflammation  the  anatomical  and  functional  disorders  of 
neighbourhood  and  the  general  symptoms  take  quite  a  different 
character :  the  neighbouring  organs  are  displaced,  their  relationships 
altered  ;  the  uterus  especially  is  pushed  back,  deviated  or  flexed ; 
there  is  compression  of  the  bladder,  rectum,  pelvic  vessels  and  nerves ; 
there  is  a  permanent  state  of  congestion  round  the  phlegmon  or  pelvic 
peritonitis,  especially  in  the  uterus,  which  is  hypersemiated,  and  the 
chronic  congestion  of  which  often  accompanies  peri-uterine  inflamma- 
tion; hence  pain,  leucorrhoea,  menstrual  disorders,  the  period  being 
usually  advanced  and  prolonged,  though  the  quantity  is  rarely  in- 
creased, but  there  is  often  gradual  diminution  or  suppression;  dis- 
ordered menstruation  reacts  on  the  perimetritis  itself,  causing  increase 
of  pain ;  sometimes  persistence  of  the  peri-uterine  inflammation  pro- 
duces hypertrophy  of  the  uterus,  especially  in  multiparae.  Marital 
intercourse  is  nearly  always  painful,  and  should  be  forbidden.  It  is 
less  so  when  the  inflammation  is  in  the  broad  ligaments,  and  not 
immediately  in  contact  with  the  uterus.  Chronic  peri-uterine  inflam- 
mation is  not  an  absolute  obstacle  to  conception  unless  there  are 
abnormal  adhesions  of  the  Fallopian  tubes;  but  in  the  few  cases  in 
which  pregnancy  occurs  there  is  undoubtedly  a  risk  of  miscarriage 
from  mechanical  and  physiological  causes,  therefore  treatment  should 
be  continued  during  pregnancy.  Micturition  is  frequent  and  painful, 
accompanied  by  tenesmus  and  sometimes  by  retention.  There  is  often 
constipation,  at  other  times  diarrhoea  by  propagation  of  the  inflamma- 
tion. At  other  times  defecation  is  painful  and  difhcult,  the  rectum 
and  anus  being  the  seat  of  spasmodic  contractions  causing  real  nervous 
attacks ;  the  feces  are  discharged  as  if  moulded  in  a  tube  no  larger 
than  a  pen,  and  are  covered  with  mucus,  showing  the  existence  of 
glairy  enteritis ;  there  are  hsemorrhoids  and  even  anal  fissures.  The 
stomach  is  affected  sympathetically  as  in  metritis  and  leucorrhoea; 
there  is  usually  loss  of  appetite,  slow  digestion,  weight  with  epigastric 
swelling  after  meals,  depraved  taste,  heat,  epigastric  dragging,  gaseous 
eructations,  nausea,  vomiting,  &c.     Respiration  is  often  difficult,  and 


PEEI-UTEEINE    INFLAMMATION  645 

accompanied  by  a  dry  nervous  cough.  Pever  appears  with  every 
paroxysm ;  in  many  patients  the  pulse  is  moderately  but  continuously 
quick,  or  there  may  be  a  recurrence  of  this  frequency  in  the  evening 
after  fatigue.  In  some  women  disorders  of  sensibility  and  motility 
are  added  to  these  general  symptoms.  Lastly,  chloro-ansemia  and 
debility  are  usually  the  most  marked  general  symptoms. 

The  course  of  the  malady  may  help  in  the  diagnosis. 

Puerperal  peri-uterine  inflammation  passes  rapidly  and  frequently  to 
suppuration.  Non-puerperal  perimetritis  has  a  slower  course.  It 
may  terminate  in  three  ways :  by  resolution  after  gradual  diminution 
of  the  symptoms  in  two  or  three  weeks  or  at  the  normal  recurrence  of 
the  second  monthly  period;  by  transition  to  the  chronic  stage,  in 
which  case  the  tumour  remains  stationary  and  becomes  indurated ;  or 
by  suppuration,  which  is  the  rarest  case.  The  malady  progresses  very 
slowly  except  in  a  few  cases,  when  it  terminates  by  sudden  generalisa- 
tion of  the  peritonitis.  Even  in  the  most  fortunate  cases  patients 
suffer  a  long  time  from  debility  and  nervous  symptoms,  pelvic  weight, 
lumbar  pain  on  standing,  and  pain  in  the  accomplishment  of  the  sexual 
functions.  The  abdomen  is  painful  on  pressure ;  traces  of  the  tumour 
exist,  either  peri-uterine  pufiiness,  or  small  tumours  of  the  size  of  a 
pea,  so  well  described  by  Gosselin,  tumours  which  are  not  perhaps 
always  vestiges  of  peri-uterine  inflammation,  but  which  may  often  pass 
for  a  remnant  of  this  malady;  so  that  resolution  of  the  peri- uterine 
inflammation  perhaps  is  never  complete — at  least  it  is  very  slow. 
Usually  the  malady  passes  to  the  chronic  state  with  or  without  inflam- 
matory paroxysms.  Death  may  occur  in  one  of  these  paroxysms  by 
generalisation  of  the  peritonitis,  putrid  absorption,  or  even  by  purulent 
infection  (Aran  has  seen  it  twice). 

At  other  times  the  neo-membranous  peritonitis  favoured  by  these 
inflammatory  paroxysms  may  be  vascularised  and  hypereemiated  to  the 
point  of  causing  hsemorrhages,  which  again  are  the  sources  of  new 
maladies  (hematoceles),  and  which  have  won  the  name  of  hsemorrhagi- 
parous  pachy-peritonitis.  At  other  times,  after  having  passed  through 
several  paroxysms  and  escaped  their  dangers,  patients  find  their  health 
gradually  improved.  If,  however,  they  are  tuberculous  they  continue 
to  suffer,  now  from  the  chest,  now  from  pelvic  peritonitis,  till  con- 
sumption at  last  ends  in  death. 

Objective  signs. — At  first  it  is  difficult  to  perceive  the  pelvic  tumour 
by  abdominal  palpation.  But  when  the  tumour  increases  and 
approaches  the  surface  we  discover  in  the  centre  of  the  hard  abdomen 
a  tumour,  which  may  or  may  not  be  circumscribed,  as  large  as 
the  fist  and  more  painful  than  the  surrounding  parts  on  pressure. 
In  chronic  peri-uterine  inflammation  the  belly  is  always  sensitive  to 
pressure  and  sometimes  distended;  palpation  reveals  marked  resistance 
or  a  real  tumour,  flattened  or  rounded,  which  may  reach  to  the 
umbilicus,  or  farther. 

Digital  touch  is  not  possible  in  the  commencement  of  acute  peri- 
metritis, the  vagino-uterine  pain  being  too  great  to  allow  of  it ;  but  as 

35 


546  UTERINE    DISEASES    IN    DETAIL 

soon  as  the  pain  is  somewhat  less  intense  this  examination  is  indispen- 
sable in  order  to  prevent  the  consequences  of  the  phlegmon. 

It  is  usually  easy  to  discover  a  globular  projection  with  smooth, 
regular,  resisting  surface,  hot,  painful,  and  projecting  into  the  vagina, 
rectum  or  hypogastrium.  There  is  marked  vaginal  heat,  the  vulvo- 
uterine  canal  being  more  or  less  moistened  with  mucus.  The  cervix 
varies  in  position,  but  appears  fixed  on  a  solid  base;  the  fundus  is 
immobile  ;  the  utero-vaginal  cul-de-sac  offers  at  some  points  a  certain 
resistance,  puffiness  or  a  projection,  sometimes  in  the  form  of  a  semi- 


TiG.  318. — Phlegmon  of  the  broad  ligament,  partially  surrounding  the  cervix 

(after  Barnes). 

circle  (Fig.  318).  Immobility  of  the  uterus  and  an  imperfectly  circum- 
scribed peri-uterine  tumour,  together  with  the  general  phenomena 
suffice  to  diagnose  the  malady. 

In  chronic  inflammation  digital  touch  shows  the  uterus  to  be  com- 
pletely immobile,  either  in  its  normal  position  or  inclined,  or  in  a  kind 
of  gangue  from  which  the  neck  alone  is  free,  or  closely  attacked  to  a 
lateral  or  posterior  tumour,  or  pushed  back  in  an  opposite  direction 
from  the  tumour,  from  which  the  cervix  is  separated  by  a  groove, 
sometimes  with  cedema  of  the  neck  and  upper  part  of  the  vagina. 
Eectal  touch  enables  us  better  to  recognise  a  shapeless  mass,  or  bands, 
or  a  more  or  less  complete  ring  fixing  the  uterus.  Lastly,  the  asso- 
ciation of  palpation  with  digital  touch  allows  the  extent  of  the  tumour 
to  be  appreciated,  its  thickness,  its  consistency,  its  elasticity  announc- 
ing the  formation  of  pus,  &c.  The  association  of  vaginal  and  rectal 
touch  has  been  successfully  employed  by  Recamier  to  discover  sup- 
puration, by  determining  fluctuation  in  the  tumour.  As  for  the  ovary 
and  Fallopian  tube,  they  are  too  much  in  the  centre  of  this  tumour  to 
be  accessible  to  touch. 

Peri-uterine  inflammation  always  leads  to  the  formation  of  a 
tumour.  This  tumour  is  sometimes  apparent  above  the  pubis, 
through  the  abdominal  walls ;  its  presence  can  be  verified  by  manual 
examination,  hypogastric  palpation,  association  of  vaginal  with  rectal 
touch.     It  may  vary  much  in  form  and  volume,  from  the  size  of  an 


PERI-UTERINE   INFLAMMATION  547 

almond  to  that  of  an  orange,  and  may  be  either  circumscribed  or 
diffuse.  The  surface  is  generally  regular  and  smooth,  \idthout  soft 
depressible  projections  like  those  produced  by  stercoraceous  accumula- 
tions in  the  rectum  ;  in  consistency  it  is  solid,  firm,  sometimes  hard, 
generally  elastic,  like  that  of  the  body  of  the  uterus  unless  there  is 
suppuration.  This  tumour  is  sometimes  mobile  relatively  to  the 
uterus,  sometimes  adherent  to  this  organ,  either  by  one  end,  or  by 
one  surface;  it  is  not  on  that  account  necessarily  immobile  in  the 
pelvis,  it  may  be  limited  to  the  folds  of  the  broad  ligaments  to  which 
it  adheres  by  one  surface,  whilst  the  other  is  free ;  in  fact  it  is  usually 
fixed  and  immobile  in  the  pelvis  and  round  the  uterus  or  at  one  part 
of  this  organ. 

Digital  touch  shows  the  parts  occupied  by  the  tumour.  Nonat 
says  Vndii phlegmon  usually  begins  with  one  of  the  broad  ligaments  and 
from  there  spreads  inwards  towards  the  uterus  or  outwards  towards 
the  iliac  fossae.  This  writer  distinguishes  besides  this  phlegmon  of  the 
broad  ligaments,  latero-uterine  phlegmon  (the  most  frequent  after  the 
preceding),  then  antero-uterine,  retro -uterine,  and  lastly,  that  which 
makes  a  belt  round  the  womb  meriting  the  name  of  peri-uterine,  and 
perhaps  the  peri-rectal. 

West^s  statistics  give  us  an  idea  of  the  comparative  frequency  with 
which  the  different  parts  are  affected  :  out  of  52  cases  the  broad  liga- 
ment was  the  seat  34  times,  the  utero-rectal  cellular  tissue  14  times, 
the  utero-vesical  cellular  tissue  3  times. 

Pelvic  peritonitis  is  also  more  common  laterally  than  in  the  median 
portion,  the  ovary  or  Pallopian  tube  being  the  usual  starting  point. 
As  to  frequency,  peri-uterine  inflammation  evidently  has  a  tendency  to 
attack  the  postero-lateral  part  to  the  right  or  left  indifferently,  except 
in  puerperal  women  when,  Aran  says,  the  proportion  seems  rather 
larger  to  the  right. 

The  statistics  of  Gallard  and  Aran  confirm  those  of  West  in  this 
respect. 

In  52  cases,  West  found  34  on  one  side,  21  to  the  left. 
„    53      „      Gallard    „    32       ,,         ,,       11        „ 
„    24      „      Aran         „    17       ,,         „ 

Next  to  the  lateral,  the  posterior  part  or  the  utero-rectal  eul-de-sac 
is  the  most  frequent  seat  of  peri-uterine  inflammation.  Peri-uterine 
adenitis  is  also  more  frequent  behind  and  on  one  side,  usually  on  the 
right. 

There  is  another  sign  perceptible  by  digital  touch  to  which  Nonat 
attributes  great  importance  :  usually,  he  says,  a  tolerably  large  arterial 
vessel,  as  large  for  instance  as  the  radial,  creeps  round  the  base  of  the 
tumour  giving  pulsations  perceptible  to  the  touch.  It  is  only  to  be 
found  in  old  tumours ;  it  can  be  observed  in  the  third  month  but 
more  clearly  in  the  eighth ;  it  is  never  absent  from  peri-uterine 
engorgements  of  a  yearns  standing,  but  it  may  not  be  accessible  to 
exploration.  Its  volume  is  proportioned  to  the  age  of  the  phlegmon, 
it  aggravates  the  prognosis,  the  afflux  of  a  larger  quantity  of  blood 
making  the  malady  more  difficult  to  treat.     These  remarks  of  Nonat's 


548  UTEEINE    DISEASES    IN    DETAIL 

are  mentioned  in  Martinis  ^  thesis.  Arterial  pulsations  may  be  per- 
ceived in  peri-uterine  tumours;  but  I  think  this  writer  exaggerates 
their  importance. 

Differential  diagnosis. — Acute  but  especially  chronic  peri-uterine 
inflammations  have  been  long  ignored ;  they  have  given  rise  to  many 
errors  of  diagnosis ;  we  may  even  affirm  that  such  errors  continue  to 
be  made.  We  must  therefore  lay  down  the  basis  for  a  serious  diag- 
nosis. Every  unusual  phenomenon  produced  in  the  abdominal  region, 
especially  when  accompanied  by  disturbance  of  the  general  health, 
whether  it  occur  after  labour  or  not,  ought  to  attract  the  attention  of 
the  physician  leading  him  to  fear  peri-uterine  inflammation  (for  this 
malady  occurs  50  or  70  times  out  of  100  diseases  of  the  utero-ovarian 
economy),  and  induce  him  to  make  a  minute  examination,  especially 
after  delivery  or  abortion,  even  when  this  has  taken  place  two  months 
ago  (for  the  disease  may  have  been  misunderstood  till  then)  ;  or  even 
if  there  was  another  malady  (for  perimetritis  may  coexist  with  it. 

1.  Special  signs  of  the  various  peri-uterine  inflammations. — They 
establish  a  distinction  between  perimetritis,  parametritis,  phlegmon  of 
the  broad  ligaments,  peri-uterine  adenitis. 

Although  Thomas,^  Bernutz,^  and  other  writers  have  tjied  to 
enumerate  these  signs,  it  is  very  difficult  to  find  sufficient  reasons  for 
deciding  whether  we  have  to  do  with  a  case  of  perimetritis,  para- 
metritis, or  phlegmon  of  the  broad  ligaments,  whether  it  be  that  they 
coexist,  or  that  the  distinctive  signs  are  not  sufficiently  pathogno- 
monic. It  is  not  often  that  a  physician  can  be  sure  as  to  the  seat  of 
inflammation,  except  when  he  has  been  called  in  at  the  beginning  and 
has  seen  the  malady  follow  its  course,  terminating  by  resolution  or 
suppuration,  the  abscess  having  opened  at  some  point  or  another. 
There  are  also  cases  when  we  have  to  do  simultaneously  with  peri- 
tonitis and  pelvic  cellulitis.  As,  however,  these  diseases  may  be 
absolutely  independent  of  each  other,  each  existing  separately,  I  shall 
endeavour  to  give  the  difl'erential  diagnosis  of  peritonitis  and  simple 
pelvic  cellulitis,  after  having  described  the  complicated  morbid 
states  which  most  frequently  occur  under  these  names,  just  as 
I  have  before  endeavoured  to  bring  into  relief  the  characters  of 
simple  ovaritis  amidst  symptoms  of  complicated  ovaritis  which  is  also 
commoner. 

Teri-uterine  cellulitis  or  pelvic  c^^/?<;^i^M,  especially  when  situated  on 
a  level  with  the  cervix,  is  so  rare  that  its  existence  has  been  denied; 
it  has,  however,  been  seen  after  traumatisms  and  extension  of  inflam- 
mation of  the  broad  ligaments :  it  is  a  median  parametritis,  whilst 
phlegmon  of  the  broad  ligament  is  a  lateral  parametritis ;  it  has  no 
direct  connection  with  puerperal  fever.  There  is  little  or  no  shivering 
except  at  the  time  of  suppuration;  dull  pain  from  the  abscess,  and 
feverish  pulse.     The  tumour  may  be  felt  all  round  the  cervix  project- 

^  Phlegmons  des  ligaments  larges  et  du  Ussu  cellulaire  peri-uterin.  Paiis, 
1851. 

^  Diseases  of  Women,  pp.  366,  375. 
^  Op.  cit.,  t.  ii,  p.  397,  et  seq. 


PERr-UTERINE    INFLAMMATION 


549 


ing  either  in  front  between  the  bladder  and  uterus  raising  the  vagina, 
or  behind  between  the  retro-uterine  peritoneum  and  the  womb  raising 


Fig.  319.— Pelvic  cellulitis  and  pelvic  abscess  encysted  to  the  right  of  the 
uterus,  seen  from  the  front,  from  a  case  observed  at  University  College 
Hospital  (after  Graily  Hewitt). 


i    m  I K  mil  7    f/f^^ 


Fig.  320. — Right  pelvic  cellulitis,  same  tumour  seen  in  profile. 

the  posterior  vaginal  cul-de-sac,  or  laterally  whence  it  extends  to  the 
broad  ligament,  forming  a  hard  surface  on  the  side  corresponding  to 
the  vagina;  more  frequently  it  is  from  the  broad  ligament  that  the 
inflammation  extends  to  the  circumference  of  the  cervix;  it  is  slowly 
developed,  not  being  perceived  for  some  days  ;  it  is  very  circumscribed 
hardly  rising  except  when  it  attacks  the  broad  hgament ;  it  cannot  be 
perceived  above  the  brim;  it  is  hemispherical  and  annular,  sometimes 
very  hard  in  the  centre,  and  oedematous  externally ;  the  oedema  may 
extend  to  the  cervix  on  one  side  and  to  the  vulva  on  the  other ;  later 


550  UTERINE    DISEASES    IN    DETAIL 

on  it  becomes  puffy  and  fluctuation  appears;  the  tumour  is  immobile. 
The  uterus  is  not  completely  immobile,  only  its  mobility  is  limited  in 
one  direction  or  another  according  to  the  seat  of  the  phlegmon;  it  is 
the  same  as  to  its  direction^  which  may  also  be  altered.  The  groove  of 
separation  between  the  uterus  and  the  tumour  may  not  exist  or  is 
inappreciable.  The  pain,  which  varies  with  the  stage  of  the  disease,  is 
elicited  by  micturition  or  defecation  according  to  the  seat  of  the 
trouble ;  dysuria  is  not  uncommon ;  pain  is  also  caused  by  the  pressure 
of  the  finger  in  the  vagina.     There  are  no  signs  of  peritonitis ;  fever  is 


Fig.  321. — Pelvic  cellulitis  or  right  pelvic  phlegmon,  which  has  spi-ead  from 
the  broad  ligament,  on  one  side  round  the  uterus,  on  the  other  side  into 
the  iliac  fossa.  Parnell's  case,  preserved  in  TJnivei-sity  College  Hospital, 
front  view  (after  Graily  Hewitt). 

sometimes  high ;  there  is  no  tendency  to  relapses ;  duration  is  limited ; 
there  is  marked  tendency  to  suppuration ;  termination  is  by  resolution, 
suppuration  or  induration,  which  in  all  cases  diminishes  the  size  of  the 
tumour  causing  its  disappearance,  unless  some  centres  of  induration 
persist  in  its  place.  Sometimes,  on  the  contrary,  the  phlegmasia 
extends  towards  the  periphery  of  the  pelvic  cellular  tissue,  towards  the 
pubic  or  obturator  region,  towards  one  of  the  iliac  fossse,  all  round  the 
rectum.  But  the  favourite  seat  of  cellulitis  is  the  broad  ligament,  i.  e. 
the  point  where  the  connective  tissue  is  contained  between  the  two 
folds  of  peritoneum  enclosing  in  their  upper  wings  the  ovary,  the  ovi- 
duct and  the  round  ligament. 

Phlegmon  of  the  broad  ligaments  (utero-pelvic  cellulitis)  is  frequent; 
it  is  a  common  malady  in  the  puerperal  state,  and  may  be  developed 
from  the  second  to  the  twentieth  day  after  labour :  it  may  be  seen  in 
nulliparae  and  even  in  virgins,  but  is  rare  in  the  state  of  vacuity. 
Eigor  is  not  constant,  occurring  only  in  about  half  the  cases ;  fre- 
quently it  is  only  produced  at  the  time  of  the  formation  of  pus.  There 
is  dull  pain  in  the  abscess,  darting  at  intervals,  with  a  feverish,  full 
pulse.  The  tumour  is  lateral  and  not  median  as  in  pelvic  peritonitis, 
extending  easily,  generally  perceived  in  the  broad  ligament,  and  above 
the  margin  of  the  pelvis ;  from  the  first  there  is  the  sensation  of  a 
cord  when  abdominal  palpation  is  practised   (if  when  the  uterus  is 


PEEI-UTEEINE    INFLAMMATION 


;5i 


seized  with  the  thumb  and  middle  finger,  they  are  passed  along  the 
sides  of  the  organ  from  above  downwards,  in  place  of  the  soft  and 
supple  annexes  a  cord  is  encountered,  directed  from  the  cornua  of  the 
uterus  towards  the  anterior  part  of  the  iliac  fossae;  this  cord  is  hard, 
tense,  and  always  painful  on  pressure  at  the  enlarged  point);  the 
tumour  is  sometimes  hardly  accessible  to  vaginal  touch ;  always  to  be 
felt  at  the  hypogastrium  from  the  beginning,  owing  to  the  tendency 
of  the  inflammation  to  be  propagated  to  the  neighbouring  areolar 
tissue,  especially  in  the  iliac  fossa ;  it  is  sometimes  developed  indis- 
tinctly and  slowly,  the  reverse  of  pelvic  peritonitis ;  it  is  generally  first 
perceived  on  the  sides  of  the  pelvis,  probably  because  it  commences 


Fig.  322. — Phlegmon  of  the  left  broad  ligament  pushing  back  the  uterus  to 
the  right,  with  diffusion  into  the  pelvis.  Formation  of  an  abscess.  Open- 
ing by  the  inguinal  canal  (round  ligament),  below  the  crural  arch,  by  the 
obtra'ator  foramen  on  the  left  side  of  the  vagina  (Courty). 

where  the  cellular  tissue  is  loose ;  it  is  probably  also  for  the  same 
reason  that  it  extends  to  the  internal  iliac  fossa,  the  anterior  abdominal 
wall,  the  crural  canal  and  to  the  buttock,  as  well  as  to  the  side  of  the 
uterus ;  tumefaction  is  perceived  later  on  at  the  side  of  the  womb  on 
account  of  the  condensation  of  the  cellular  tissue  at  this  point,  thus  it 
generally  progresses  from  the  periphery  to  the  centre  and  from  above 
downwards ;  it  may  commence  or  terminate  by  inflammation  of  the 
utero-ovarian  veins  and  pampiniform  plexus.  Percussion  gives  a  dull 
sound  laterally,  a  clear  sound  in  the  middle  of  the  hypogastrium.  By 
vaginal  touch  the  tumour  is  felt  at  the  bottom  of  the  lateral  cul-de-sac 
on  the  sides  of  the  vagina  and  cervix,  under  the  form  of  an  cedematous 
plaque,  sometimes  as  hard  as  wood  and  regular,  often  without  either 
indentations  or  irregularities,  not  sensitive  and  almost  completely 
immobile;  the  internal  part  embraces  the  cervix  with  which  it  is 
continuous,  or  from  which  it  is  only  separated  by  a  narrow  groove ;  at 
the  border  of  the  cul-de-sac  the  induration  may  double  on  itself  and 
be  prolonged  round  tlie  walls  of  the  vagina,  sometimes  even  the  latter 
is  to  a  great  extent  enveloped  in  this  kind  of  lining ;  the  tumour  then 
becomes  soft,  pasty  and  fluctuating. 


562 


UTEEINE    DISEASES    IN    DETAIL 


As  in  internal  abscesses,  oedema  appears  in  the  superficial  parts  and 
neighbouring   tissues :    thus    the   cervix,  vagina    and    corresponding 
labium   are  manifestly  (Edematous ;  this   fact,  to  which  I  have  often 
called  attention,  has  not   been  sufficiently  noticed   as  an  element  of 
differential  diagnosis.     The  uterus  is  only  fixed  to  a  limited  extent;  in 
place  of  being  completely  immobile  as  in  pelvic  peritonitis,  it  preserves 
a    portion    of  its   mobility,  its    lateral   movements    only  being  very 
restricted;  the  organ  is  not  displaced  if  the  phlegmon  is  small;  in  the 
contrary  case  there  may  be  three  kinds  of  displacement,  answering  to 
differences  of  extent  and  seat  in  the  phlegmon ;  if  the  tumour  occupies 
the  whole  broad  hgament,  the  uterus  is  inclined  to  tbe  other  side;  if 
it  is  less  developed,  it  is  the  fundus  or  the  cervix  which  is  pushed  back 
to  the  opposite  side,  according  to  whether  it  is  the  upper  or  lower 
part  of  the  broad  ligament  which  is  the  seat  of  the  tumefaction ;  after 
cure,  owing  to  the  retraction  of  the  inodular  tissue  the  uterine  dis- 
placement is  the  reverse  of  what  it  was  originally.     The  groove  sepa- 
rating the  uterus  from  the  tumour  is  absent  or  hardly  apparent.     The 
dull,  heavy,  strong,  continuous  pain  has  nothing  in  common  with  that 
of  peritonitis ;  it  is  caused  by  micturition  more  than  by  defecation,  is 
eHcited  by  pressure  on  the  lateral  portion  of  the  vagina  and  on  the 
hypogastrium  above  the  crural  arch.      Shortening  of  the  thigh  is  very 
common,  although  not  as  constant  as  in  sub-aponeurotic  abscesses,  and 
especially  inflammations  of  the  psoas  and  internal  iliac  fossa.     There 
are  no  general  signs  of  peritonitis ;  no  nausea,  nor  excessive  vomiting 
nor  tympanitis,  nor  alteration  of  the  face,  nor  concentrated  pulse. 
Febrile  phenomena  predominate    over  functional  alterations   of  the 
digestive  economy  :  the  latter  are  more  like  the  symptomatic  digestive 
disorders  of  pregnancy  or  those   of  a  malady  of  the  fundus  than  of 
peritonitis.     There  is   marked  tendency  to   suppuration  and  to   the 
formation  of  abscesses,  but  no  tendency  to  monthly  relapses.     The 
duration  of  the  malady  is  limited  and  varies  according  to  whether  it 
terminates  by  resolution,  induration  or  suppuration. 

Pelvic  peritonitis  is  very  common  whether  puerperal  or  non-puerperal, 
acute  or  chronic.  It  may  occur  in  the  state  of  vacuity,  as  a  sequence 
of  menstrual  disorders,  ovaritis,  traumatism  or  abortion.  When  puer- 
peral it  is  developed  during  the  first  ten  days,  generally  sooner  than 
phlegmonous  inflammation.  Shivering  is  never  absent,  especially  at 
the  outset.  la  the  beginning  pain  is  acute  and  at  one  point,  recalling 
that  of  pleurisy;  the  pulse  is  frequent,  hard  and  concentrated.  The 
tumour  is  usually  situated  in  the  utero-rectal  cul-de-sac ;  but  it  may 
be  perceived  at  several  other  points  round  the  uterus,  though  it  does  not 
project  much  except  in  the  posterior  vaginal  cul-de-sac,  where  the 
longest  prolongation  of  the  peritoneum  is  found.  The  efl'ects  of  it  are 
felt  sooner  than  those  of  phlegmon,  on  account  of  the  rapid  develop- 
ment of  peritonitis  and  adhesions ;  at  first  it  attacks  the  lowest  parts 
extending  from  below  upwards  and  from  the  centre  to  the  periphery 
(unless  the  Eallopian  tube  or  ovary  have  been  the  starting-point) ;  it 
does  not  rise  above  the  brim  unless  there  have  been  successive  attacks 
of  inflammation  or  extension  of  the  disease  to  the  whole  peritoneum  ; 


PEEI-UTEEINE    INFLAMMATION 


553 


it  depresses  tlie  posterior  vaginal  cul-de-sac  to  the  point  of  descending 
below  the  cervix,  but  not  round  the  walls  of  the  vagina;  it  is  hemi- 
spherical, rounded,  often  indented  and  irregular ;  projecting  into  the 
vagina  in  front,  into  the  rectum  behind  ;  it  is  resistant  and  hard,  but 
not  woody  nor  (edematous ;  it  is  immobile.     The  uterus  is  also  im- 


FiG.  323. — General  pelvic  peritonitis,  rising  to  below  the  umbiHcus,  seen  in 
front,  raising  the  uterus  and  annexes. 


Fig.  32'1'. — General  pelvic  peritonitis  and  intra-peritoneal  pelvic  abscess,  seen  in 
profile,  felt  through  the  vagina  and  hypogastrium  (after  Graily  Howitt). 

mobile  in  every  direction,  fixed  by  the  tumour  and  always  displaced ; 
the  neck  is  deviated  either  to  the  side  of  the  tumour  or  to  the  opposite 
one,  according  to  whether  it  presses  on  the  body  or  neck ;  usually  the 
whole  organ  is  pushed  upwards  and  forwards  towards  the  pubis.  The 
groove  separating  the  uterus  from  the  tumour  is  always  appreciable. 
Pain  is  often  very  acute ;  it  is  elicited  by  defecation,  digital  pressure 


554 


UTERINE    DISEASES    IN    DETAIL 


in  the  vagina  and  by  pressure  over  the  hypogastrium :  the  tumour 
is  never  indolent. 

A  vague,  diffuse,  resistant  tumefaction  is  felt  through  the  abdominal 
walls  when  the  pain  is  not  extreme ;  usually  excessive  abdominal  sen- 
sitiveness is  developed  above  the  pelvis^  towards  the  median  line  ; 
shortening  of  the  thigh  never  occurs.  The  general  signs  of  peritonitis 
are  manifested  :  excessive  pain,  frequently  with  paroxysms,  prostration, 
the  face  drawn  and  anxious,  nausea,  green  vomiting,  distension  of  the 
belly,  tympanitis,  quick  and  concentrated  pulse ;  the  digestive  sym- 
ptoms predominate  over  the  febrile  phenomena.  But  slight  tendency 
to  suppuration,   marked  tendency  to    monthly  relapses ;  duration  is 


Pig.  325.—  Left   lateral    pelvic    peritonitis,  encysted,    with   pelvic  peritoneal 
abscess  surrounding  the  ovary,  tube  and  uterus  with  adhesions. 

long,  the  malady  being  prolonged  by  frequent  recurrences  to  the  acute 
state.  In  short,  acute  perimetritis  is  more  easily  confounded  with 
retro-uterine  hematocele  than  with  phlegmon  of  the  broad  ligaments. 

Ten-uterine  adenitis  follows  pelvic  cellulitis,  pelvic  peritonitis,  or 
more  frequently  still  chronic  endometritis  with  leucorrhoea  and  ulcera- 
tion ;  it  hardly  forms  a  tumour ;  it  is  perceived  by  the  touch  in  the 
form  of  indentations,  nodosities  and  induration  in  the  connective  tissue 
of  the  base  of  one  of  the  broad  ligaments  and  the  posterior  region  of 
the  uterus.  It  scarcely  alters  the  mobility  of  the  uterus.  It  is  painful 
on  pressure  and  when  the  uterus  is  moved ;  it  lasts  long ;  cure  is  diffi- 
cult ;  there  are  hardly  any  relapses  or  inflammatory  paroxysms,  but  on 
the  other  hand  there  is  no  tendency  to  resolution. 

2.  Distinctive  signs  of  peri-uterine  inflammations  and  other  maladies 
of  the  uterus,  its  annexes  and  of  the  pehic  cavity.-^— Acute  metritis 
is  distinguished  by  less  intensity  of  the  general  and  local  phenomena, 
by  the  different  seat  of  pain,  which  occupies  the  whole  belly,  by  its 
expulsive  character,  by  leucorrhoea,  more  frequent  vomiting,  the 
absence  of  a  tumour  and  especially  by  the  mobility  of  the  uterus,  which 
is  recognised  as  the  only  tumour  occupying  the  centre  of  the  hypogas- 
trium.— Simple  ovaritis  forms  a  smaller  tumour  than  that  of  peri- 
metritis, smooth,  mobile,  very  painful,  raised  behind  the  body  and  one 


PEEI-UTERINE    INFLAMMATION  555 

of  the  borders  of  the  uterus  ;  when  complicated,  it  is  the  centre  of  true 
pelvic  peritonitis. —  Simple  salpingitis  forms  an  elongated  tumour, 
either  knotted  or  globular,  perceptible  by  palpation  associated  with 
touch,  on  one  side  of  the  uterus,  being  continuous  with  one  of  the 
cornua;  when  complicated,  it  also  is  the  centre  of  true  pelvic  peri- 
tonitis.— Cystitis  is  known  by  examination  of  the  urine  and  is  easily 
distinguished  from  perimetritis. 

The  diagnosis  of  chronic  perimetritis  is  the  most  difficult.  Engorge- 
ment of  the  uterine  walls  is  less  hard  than  peri-uterine  phlegmon,  and 
can  be  slightly  depressed.  It  is  not  limited  to  one  side  or  to  one  part 
of  the  uterus ;  there  is  no  border  round  the  neck,  nor  any  groove  indicat- 
ing the  boundary  between  the  womb  and  the  peri-uterine  engorgement. 
Pregnancy  is  distinguished  by  the  uniform  development  of  the  body 
of  the  uterus,  which  is  globular,  without  any  groove,  of  normal  con- 
sistency, increasing  daily  in  size.  Interstitial  fibrous  tumours  are 
distinguished  by  the  same  characters,  by  the  absence  of  any  groove,  by 
hardness,  absence  of  sensibility,  the  less  frequent  existence  of  arterial 
pulsations,  the  mobility  which  the  uterus  preserves  in  spite  of  its 
increased  size.  Fibromata  and  sub-peritoneal  myotnata  may  occupy  the 
cavity,  making  diagnosis  difficult.  We  must  remember  that  they  are 
.harder,  round,  often  multiple,  more  or  less  mobile,  indolent,  &c.  They 
sometimes  become  enormous.  Deviations  d^udi  flexions ,  which  have  given 
rise  to  frequent  errors,  are  distinguished  by  the  fact  that  the  body  of 
the  uterus  can  be  found  nowhere  apart  from  the  tumour.  The  uterus 
must  be  held  simultaneously  with  the  tumour,  to  be  quite  certain  that 
the  latter  exists ;  the  sound  facilitates  the  diagnosis. 

Amongst  extra-uterine  tumours,  iMegmon  of  the  internal  iliac  fossa 
has  a  recognised  seat  and  boundaries.  In  order  to  feel  it  the  abdomen 
should  be  depressed  behind  the  ilium,  and  not  behind  the  crural  arch ; 
no  tumour  is  found  in  the  cavity  by  vaginal  touch ;  the  cuts- de-sac  are 
free  and  supple,  the  uterus  quite  mobile;  the  thigh  is  flexed,  the 
nerves  supplying  it  and  the  genital  organs  are  the  seat  of  neuralgia. 
If  the  peri- uterine  cellular  tissue  is  invaded  no  distinction  can  be 
made ;  it  is  the  same  malady,  differing  only  as  to  seat  and  extent. 
Tumours  formed  in  the  rectum  by  retention  of  stercoraceous  matter 
have  led  to  mistakes.  They  are  sometimes  soft  and  depressible,  some- 
times hard  and  indented ;  they  can  be  recognised  by  rectal  touch ;  an 
enema  given  several  days  running  removes  all  doubt.  Sometimes  the 
two  maladies  are  observed  simultaneously,  for  the  coexistence  of  a 
peri-uterine  phlegmon  with  constipation  is  not  uncommon.  Peri- 
uterine hematocele  is  perhaps  the  malady  which  can  most  easily  be 
confounded  with  acute  sero-adhesive  pelvic  peritonitis.  There  is  more 
resemblance  between  these  two  diseases  than  between  pelvic  peritonitis 
and  peri-uterine  or  latero-uterine  phlegmons.  Nevertheless,  hemato- 
cele does  not  commence  under  the  same  circumstances  or  in  the  same 
way  ;  the  history  of  the  case  gives  the  clue  to  the  differential  diagnosis. 
It  frequently  follows  sudden  suppression  of  the  menses.  The  forma- 
tion of  the  tumour  is  very  rapid,  and  is  accompanied  by  the  general 
symptoms  of  haemorrhage,  acute  pains  like  those  of  peritonitis,  and  by 


556  UTERINE    DISEASES    IN    DETAIL 

fluctuation  from  the  beginning,  which  is  the  reverse  of  what  takes 
place  in  pelvic  peritonitis.  Pain  and  reaction  soon  make  confusion 
possible.  But  the  tumour  gradually  hardens  owing  to  coagulation  of 
the  blood,  in  place  of  softening;  it  is  not  so  sensitive  to  pressure  as  the 
inflammatory  tumour  of  pelvic  peritonitis  ;  its  usual  seat  is  behind  the 
uterus,  which  is  pushed  forwards  and  upwards  against  the  pubis.  An 
exploratory  puncture  removes  all  doubts  ;  it  is  not,  however,  necessary. 
When  hematocele  is  accompanied  by  pelvic  peritonitis,  as  happens 
in  the  most  painful  and  troublesome  cases,  it  requires  the  same  treat- 
ment as  acute  pelvic  peritonitis.  Peritonitis  furnishes  the  dominant 
symptoms  and  afi'ords  the  chief  indication. 

Tuberculisation  of  the  ovaries,  broad  ligaments  and  tubes  is  more 
difficult  to  distinguish,  for  it  is  but  a  chronic  and  diathetic  peri- 
metritis. Ci/sts,  especially  ovarian  cysts,  whether  serous  or  purulent, 
present  evident  fluctuation  unless  there  is  very  great  distension,  thick- 
ening of  their  contents,  or  too  great  multiplicity.  A  characteristic 
globular,  mobile  form  is  felt  by  the  vagina  and  hypogastrium.  They 
are  not  painful  on  pressure,  nor  is  there  any  arterial  pulsation.  Extra- 
uterine pregnancy  forms  a  heterogeneous  mass,  composed  of  soft  and 
hard  parts,  mobile,  unequal,  &c.  Perimetritis  may  coincide  with  it, 
or  with  a  serous  or  purulent  cyst.  As  for  sub-aponewotic  abscesses, 
hydatid  tumours,  cancer,  and  even  aneurisms  which  may  be  developed 
in  the  pelvic  cavity,  they  give  rise  to  pathognomonic  symptoms  which 
allow  of  their  being  easily  distinguished  from  peri-uterine  inflamma- 
tion.^  Lastly,  chronic  peri-uterine  inflammation  must  not  be  con- 
founded with  maladies  like  pulmonary  tubercle  which  are  connected 
with  diathetic  general  affections,  and  gradually  produce  consumption. 
The  antecedent  circumstances,  the  general  symptoms,  the  fades 
uterina,  dyspepsia,  the  symptoms  of  neighbourhood,  viscid  leucorrhoea, 
&c.,  lead  to  a  direct  examination,  and  consequently  to  the  differentia- 
tion of  two  maladies  which  may  indeed  coexist  in  the  same  patient. 
The  general  symptoms  may  be  analogous  and  increase  the  confusion, 
but  the  local  symptoms  and^  above  all,  the  presence  of  the  retro-uterine 
or  peri-uterine  tumour,  remove  all  doubts. 

Peri-uterine  abscess. — The  only  termination  of  perimetritis  of  which 
I  have  not  yet  spoken  because  it  presents  special  signs,  is  the  termina- 
tion by  suppuration  and  the  formation  of  pelvic  or  peri-uterine 
abscess,  called  by  Puzos  ^  and  Yan  Swieten,  depots  laitettx.  This 
termination  is  rare,  according  to  West  it  occurs  fifty-one  times  in  100 
cases,  but  according  to  Aran,  Gallard  and  Gosselin  only  from  seven  to 
ten  times  in  100.  Under  the  influence  of  crowding,  weak  constitution, 
lymphatic  temperament,  a  cachectic  state,  the  puerperal  condition,  or 
in  the  absence  of  special  treatment,  acute  peri-uterine  inflammation 
terminates  in  suppuration ;  or  under  the  influence  of  external  irrita- 
tion, a  blow,  a  fall,  or  some  menstrual  disorder,  chronic  peri-uterine 
inflammation  passes  into  the  acute  stage  and  may  become  purulent. 

>  See  Dictionnaire  encyclopedique  des  sciences  medicales,  art.  Bassin 
ipathologie) . 

'  Traite  d'accouchemenfs,  1743. 


PERI-UTEEINE    INFLAMMATION  557 

The  pus  may  be  infiltrated  or  collected  together  according  to 
whether  suppuration  is  rapid  or  slow.  1.  If  suppuration  of  the  peri- 
uterine cellular  tissue  is  rapid^  recent  diffuse  abscesses  are  formed, 
according  to  Nonat,  the  relations  of  which  vary  according  to  the  seat 
and  extent  of  the  inflammation.  There  is  a  retro-uterine  or  recto- 
uterine abscess,  which  must  be  distinguished  from  intra- peritoneal 
purulent  collections,  an  ante-uterine  or  vesico-uterine  abscess  which 
is  rare,  a  lateral  abscess  which  separates  the  folds  of  the  broad  liga- 
ment and  bathes  the  Fallopian  tube  and  ovary  in  pus.  Usually  the 
pus  spreads  round  the  uterus  filling  the  pelvis,  and  may  even  reach 
the  iliac  fossae  or  rise  to  the  umbiHcus.  There  is  no  doubt  it  happens 
much  oftener  in  peritoneal  suppuration  than  in  phlegmons.  However, 
according  to  Nonat,  fragments  of  cellular  tissue,  vessels,  nerves,  &c., 
are  found  in  the  centre.  2.  When  suppuration  is  slow,  the  pus  is 
collected  in  a  focus  enveloped  in  a  pyogenic  membrane,  forming  one 
or  more  circumscribed  encysted  tumours  in  relation  with  the  neigh- 
bouring organs,  which  may  also  possibly  result  from  a  serous  cyst,  or 
suppurating  hematocele  ;  sometimes  pus  is  formed  in  a  latent  manner, 
and  is  not  suspected  till  evacuated.  When  there  is  much  of  it  it  may 
be  supposed  to  come  from  the  peritoneal  cavity  ;  when  there  is  little, 
it  is  more  likely  to  be  from  an  ovarian  or  tubal  abscess.  From  one 
of  these  centres  which  was  larger  than  the  uterus  at  term  15  litres  of 
pus  were  evacuated.  It  may  be  accumulated  in  a  kind  of  cyst  and 
remain  there  for  a  year,  becoming  very  dense,  in  place  of  remaining 
serous,  as  when  recent.  These  abscesses  may  open  spontaneously  into 
the  peritoneum,  which  is  rare  and  is  a  cause  of  rapid  death,  or  they 
may  open  into  the  rectum  or  vagina,  or  even  into  the  bladder,  on  the 
abdominal  wall,  or  even  by  various  orifices  such  as  the  inguinal  canal, 
crural  canal,  the  obturator  foramen  or  the  sciatic  notch  (Fig.  326). 
In  one  case  which  was  verified  by  autopsy,  Seux  ^  saw  the  pus 
discharged  through  the  posterior  wall  of  the  uterus.  According  to 
Graily  Hewitt  ^  the  most  frequent  opening  is  into  the  intestine ;  it  is 
also  rather  frequent  into  the  vagina  and  bladder.  It  is  less  common 
along  the  course  of  the  vessels  or  nerves  leaving  the  pelvis.  With 
regard  to  this,  a  wide  distinction  must  be  made  between  a  perimetric 
and  a  parametric  abscess  and  one  of  the  broad  ligament.  They  have 
common  points  by  which  they  may  be  discharged,  notably  the  rectum; 
but  there  are  points  of  selection  by  which  some  open  rather  than 
others,  for  example,  the  rectum  and  bladder,  for  the  abscess  of  pelvic 
peritonitis  ;  the  abdominal  wall  or  the  groin,  for  abscess  of  the  broad 
ligament.  The  former  has  besides  a  greater  tendency  to  become 
encysted  and  to  be  tolerated,  the  latter  to  ulcerate  and  discharge  the  pus. 

As  the  purulent  matter  is  discharged  at  certain  points  determined 
by  exact  anatomical  connections,  the  place  of  opening  of  the  abscess  is 
a  last  means  of  completing  the  difi'erential  diagnosis.  Suppurative 
pelvic  cellulitis  having  less  tendency  to  open  by  the  abdominal  wall 
and  into  the  intestine,  or  even  into  the  bladder  and  uterus,  may  be 

1  Bulletin  de  la  Societe  iinpdriale  de  medecine  de  Marseille,  1862,  p.  87. 
'  Op.  cit.,  p.  228. 


558 


UTEEINE    DISEASES    IN    DETAIL 


discharged  by  the  vagina  or  even  by  the  rectum,  all  round  the  anterior 
part  of  the  brim,  by  the  crural  arch,  the  inguinal  canal,  the  obturator 


Fig.  326. — Points  in  tlie  pelvic  cavity  by  which  the  pus  of  phlegmon  of  the 
broad  ligament  may  be  discharged,  a  c,  above  and  below  the  crural  arch. 
s,  the  great  sciatic  notch  ;  o,  the  small  sciatic  notch  ;  t  o,  the  obturator 
foramen  ;  1,  2,  3,  the  sacral  foramina. 

foramen,  as  vrell  as  by  the  sciatic  notches ;  I  have  seen  some  open 
simultaneously  into  the  vagina  (by  the  lateral  wall),  below  the  crural 
arch,  and  in  the  centre  of  the  buttock  at  the  highest  part  of  the  sciatic 


Fig.  327. — v,  vagina  ;  it,  uterus  ;  L  i,  upper  border  of  the  broad  ligament ;  p, 
peritoneum  in  which  sero-adhesive  or  sero-purulent  peri-uterine  inflam- 
mation is  developed  ;  l  s  p,  sub-peritoneal  space  of  the  broad  ligament 
on  each  side,  rising  to  the  upper  border  L  i,  in  which  suppuration  of  the 
phlegmon  of  the  broad  ligament  takes  place  ;  s  c,  subcutaneous  space 
where  abscesses  are  formed,  which  only  open  round  the  anus  and  vulva. 

notch,  at  a  point  through  which  an  india-rubber  bougie  might  be  ])assed 


PERI-UTEEINE   INFLAMMATION  659 

to  the  centre  of  the  pelvis  where  the  point  could  be  felt  by  vaginal 
touch  through  the  vaginal  wall. 

Suppurative  pelvic  peritonitis  then  may  be  discharged  by  the  rectum^ 
vagina,  bladder,  or  even  the  uterus,  and  at  various  points  of  the 
abdominal  wall  as  well  as  into  the  intestine,  the  sigmoid  flexure, 
csecum,  or  small  intestine.  I  have  seen  one  opening  simultaneously 
into  the  vagina,  into  the  intestine,  and  through  the  abdominal  wall  at 
a  point  more  or  less  distant  from  the  crural  arch.  Abscesses  which 
are  subcutaneous  and  subaponeurotic,  i.e.  below  the  deep  perinaeal 
aponeurosis,  open  round  the  vulva  and  anus.  The  accompanying 
figure  explains  how  it  is  that  one  abscess  should  open  at  one  point  and 
another  abscess  at  another  point. 

The  suppuration  which  follows  puerperal  perimetritis  has  a  rapid 
course,  terminating  fatally  in  a  few  days.  In  non-puerperal  peri- 
metritis, pus  may  appear  in  a  fortnight  or  even  sooner.  Nonat  does 
not  think  it  possible  that  pus  can  be  absorbed ;  however,  I  have  seen 
cases  of  the  kind,  but  the  tumours  were  small.  When,  however,  art 
does  not  intervene  at  an  early  stage,  purulent  collections  usually  make 
way  for  themselves  to  the  teguments  or  to  some  hollow  organ.  Some 
days  previously  there  is  exacerbation  of  the  symptoms,  then  suddenly 
after  a  fall,  contusion  or  effort  the  tumour  suddenly  gives  way  bringing 
relief.  Sometimes  there  is  no  particular  sensation,  at  other  times 
there  is  a  sensation  of  internal  laceration,  and  passage  of  pus  into  the 
vagina,  which  is  a  favorable  termination.  I  have  recently  seen  a  case 
of  this  kind  in  a  patient  who  would  not  allow  vaginal  puncture  to  be 
attempted,  and  in  struggling  the  abscess  broke  into  the  vagina :  cure 
soon  followed,  but  it  was  impossible  for  me  to  find  the  vagino-uterine 
orifice  by  which  the  abscess  was  discharged. 

Evacuation  may  either  be  complete  or  not ;  it  then  takes  place 
several  times.  At  the  monthly  period  the  pus  becomes  sanguinolent. 
"When  the  opening  is  made  into  the  rectum  there  may  be  tenesmus, 
dysentery,  and  the  most  serious  accidents,  as  Aran  once  saw  in  a 
virgin.  Except  in  cases  where  the  pus  is  effused  into  the  peritoneum, 
death  seldom  follows  rupture  of  the  abscess,  though  it  may  result 
from  prolonged  suppuration,  from  the  formation  of  fistulous  passages 
and  from  the  marasmus  into  which  patients  finally  fall.  I  have  already 
said  what  happens  when  several  openings  place  the  abscess  in  com- 
munication with  the  bladder  and  rectum  simultaneously,  sometimes 
even  with  the  abdominal  wall  as  well.  Consumption  may  occur  in 
these  cases,  as  well  as  in  those  where  the  evacuation  of  pus  is  incom- 
plete, where  the  abscess  opens  and  closes  several  times,  where  there  is 
stagnation  of  pus  owing  to  the  existence  of  only  one  opening  for  two 
or  three  abscesses.^     If,  on  the  contrary,  the  opening  is  large,  and  the 

'  Nevei-theless,  there  are  cases  in  which  the  constitution  of  patients  is  able 
to  resist  the  continued  secretion  of  pus,  perforation  of  the  digestive  canal,  &c.  ; 
I  have  just  seen  a  case  of  the  kind,  where,  in  spite  of  the  fear  of  peritoneal 
adhesions  of  the  tubes  hindering  the  adaptation  of  the  fimbriated  extremity  to 
the  ovary,  and  so  causing  sterility,  suppuration  had  hardly  ceased,  the  patient 
still  being  convalescent,  when  she  became  pregnant. 


560  UTEEINE    DISEASES    IIS    DETAIL 

abscess  well  emptied,  the  symptoms  disappear  :  hence  the  justification 
for  surgical  intervention,  the  right  limits  of  which  I  shall  try  to  define 

when  describing  treatment. 

Treatment. — Peri-uterine  inflammation,  apart  from  that  which  is 
developed  in  the  worst  conditions  of  the  puerperal  state,  is  serious,  not 
from  the  rapidity  of  the  termination,  but  from  the  long  duration  and 
natural  incurability  of  the  chronic  form,  the  constant  dangers  incurred 
by  the  paroxysms^  and  the  risk  of  consumption  which  is  all  the  more 
serious^  as  Aran  considers  that  two  thirds  of  the  women  attacked  by 
chronic  perimetritis  are  predisposed  to  tubercle.  Besides  which,  if 
the  malady  is  allowed  to  become  intense  or  be  prolonged,  sterility  fol- 
lows, except  very  exceptionally,  when  the  peritoneum  is  not  involved 
in  the  inflammation,  or  when  the  annexes  of  one  side  have  preserved 
their  integrity;  pregnancy  is  always  difiicult,  as  Madame  Boivin^  has 
shown,  but  she  attaches  too  little  importance  to  remains  of  inflamma- 
tion and  exaggerates  the  mechanical  influence  of  adhesions.  It  is 
evident  that  the  treatment  of  perimetritis  ought  always  to  be  con- 
sidered as  urgent,  and  this  should  be  explained  to  patients  as  well  as 
the  length  of  time  required. 

I  shall  not  speak  of  prophylactic  treatment,  which  consists  in 
avoiding  all  fatigue  after  delivery,  rising  too  soon,  marital  intercourse, 
cold  injections,  cold  foot  baths,  and  also  the  sudden  suppression  of 
the  milk,  but  shall  now  pass  on  to  treatment  strictly  speaking. 
The  chief  indications  are  the  following  :  1,  to  subdue  inflammation  ; 
2,  to  promote  resolution  of  the  tumour;  3,  to  treat  the  diathetic 
affection  under  the  influence  of  which  chronic  inflammation  has  a  ten- 
dency to  perpetuate  itself;  4,  to  treat  complications ;  5,  when  necessary 
to  promote  the  evacuation  of  pus. 

1.  Antiphlogistic  treatment  is  so  plainly  indicated,  that  all  physicians* 
are  agreed  as  to  its  occupying  the  first  place  in  the  treatment  of  the 
acute  form,  but  opinion  is  divided  with  regard  to  it  in  the  chronic 
form,  especially  as  to  bleeding. 

Experience  has  taught  me  the  wisdom  of  limiting  myself  to  local 
bloodletting,  though  I  do  not  deny  that  bleeding  may  be  indicated 
exceptionally  in  a  strong  woman  of  sanguine  temperament.  In  acute 
perimetritis  leeches  or  cupping  glasses  should  be  apphed  to  the 
abdomen  even  in  the  puerperal  state,  and  should  be  repeated  at  short 
intervals.  The  apparent  amelioration  effected  by  a  first  application 
associated  with  narcotics  must  not  be  trusted  to ;  fresh  applications 

^  Recherches  sur  une  des  coAises  les  phis  frequentes  et  les  moins  connues 
d'avortement.  Paris,  1828. 

^  Behier  recommends  preventive  treatment.  Whenever  the  cord  is  felt, 
which,  according  to  him,  is  the  first  sign  of  the  development  of  phlegmons  of 
the  broad  ligament,  continuous  refrigeration  is  applied  to  the  abdomen.  An 
india-mbber  bag,  two-thirds  full  of  pieces  of  broken  ice,  is  placed  over  the 
painful  region,  with  a  wet  towel  folded  in  eight  under  it,  to  prevent  its  being 
in  immediate  contact  with  the  skin,  the  whole  being  kept  in  place  by  a  large 
towel  which  allows  the  patient  to  move  without  any  danger  of  disarranging 
the  ice.  The  application  of  cold  should  be  continuous.  The  success  obtained 
by  this  treatment  has  been  described  by  Briand  in  his  thesis  and  by  Joulin  in 
his  Traits  d'accouchements,  p.  1171. 


PERT-UTERINE    INFLAMMATION  561 

should  be  made  three  or  four  days  running,  gradually  diminishing  the 
number  till  pelvic  pain  is  no  longer  elicited  by  pressure.  Leeching  is 
impossible  when  inflammation  is  very  acute  on  account  of  the  difficulty 
and  pain  caused  by  the  introduction  of  the  speculum;  but  it  should  be 
resorted  to  as  soon  as  the  local  symptoms  are  somewhat  alleviated,  as 
well  as  in  chronic  perimetritis.  Bloodletting  produced  by  leeching 
is  neither  revulsive  nor  derivative;  it  is  really  depletive.  This  deple- 
tion of  the  utero-ovarian  sanguineous  system  is  necessary  to  ensure  the 
efficiency  of  the  revulsive  and  resolvent  treatment  which  is  to  follow. 
It  has  seemed  to  me  insufficient  in  itself  to  produce  a  cure,  especially 
iu  the  chronic  forms  of  these  maladies. 

Further :  bloodletting  alone,  whether  local  or  general,  especially  in 
chronic  peri-uterine  inflammation,  as  in  all  other  chronic  phlegmasias, 
congestions  and  engorgements,  is  followed  by  a  decided  aggravation  of 
symptoms,  if  not  immediately,  at  least  subsequently.  I  have  so  often 
had  occasion  to  observe  these  troublesome  results,  that  I  have  not  the 
slightest  doubt  on  the  matter,  and  explain  the  phenomena  by  the 
increased  instability  produced  in  the  organism  by  the  debility  of  the 
patient.  As  a  rule  the  weaker  a  patient  is  the  greater  tendency  will 
there  be  to  fluxionary  movements  followed  by  more  or  less  intense 
congestion,  especially  in  the  organs  which  have  become  the  seats  of 
these  fluxionary  movements.  The  equilibrium  once  broken  is  lost  by 
increased  general  debility.  Restoration  of  tone  and  strength  to  the 
economy  can  alone  re-establish  it,  and  facilitate  the  gradual  disappear- 
ance of  local  inflammatory  phenomena.  Therefore  depletion  of  the 
utero-ovarian  vascular  system  by  leeching  the  cervix  ought  to  be  as 
complete  and  as  rapid  as  possible,  so  that  it  may  not  be  necessary  to 
recur  to  it  unless  in  cases  of  chronic  inflammation  with  exacerbations, 
which  can  never  be  removed  quickly  nor  at  once.  When  necessary, 
therefore,  I  always  make  two  or  three  consecutive  applications  after 
menstruation.  When  one  application  has  produced  a  very  abundant 
flow  of  blood  necessitating  plugging,  cure  follows  very  rapidly.  This 
depletion  of  the  utero-ovarian  vascular  system  ought  to  be  accom- 
panied not  only  by  other  antiphlogistic  means,  but  by  strong  revulsives 
and  resolvents  as  well  as  bj  tonics. 

Absolute  rest  should  be  enjoined  in  acute  inflammation;  patients 
instinctively  feel  the  necessity  for  it,  the  semi-flexed  position  being  the 
most  favorable  to  relaxation  of  the  muscles  compressing  the  inflamed 
parts.  Bernutz  rightly  insists  on  confinement  to  bed  being  prescribed 
as  for  men  in  cases  of  orchitis.  In  fact  even  in  the  chronic  form 
patients  should  take  as  much  rest  as  possible,  both  mental  and  physical, 
and  should  always  keep  their  bed  at  the  monthly  period.  Marital 
intercourse  should  be  absolutely  forbidden,  for  unless  the  suffering 
organ  has  perfect  rest  treatment  is  powerless  to  effect  a  cure.  I  agree, 
however,  with  Bernutz  that  in  the  last  stage  of  the  malady  there  is  no 
occasion  to  dread  the  occurrence  of  conception,  which  sometimes  takes 
place  easily  at  the  end  of  the  menstrual  flow.  Pregnancy  indeed  is  one 
of  the  most  efl'ectual  means  of  modifying  the  diseased  organs  and  of 
completing  the  resolution  imperfectly  produced  by  the  various  medi- 

36 


562  UTERINE    DISEASES  IN   DETAIL 

cations  employed,  that  is  if  proper  care  be  taken  during  gestation  and 
after  labour. 

In  order  to  allow  patients  to  rise  without  interfering  with  the  rela- 
tive rest  required  for  the  abdomen,  Bernutz  has  invented  a  particular 
kind  of  corset,  which  is  useful,  not  because  it  fixes  the  organs  as  he 
thinks,  but  because  it  supports  them  and  especially  prevents  the  effects 
of  shocks  during  a  period  of  the  disease  when  the  hypogastric  belt  and 
cushion  (very  superior  as  a  means  of  supporting  the  abdominal  viscera) 
could  not  be  tolerated  on  account  of  the  sensitive  state  of  the  abdominal 
region.  According  to  Bernutz  this  corset  plays  the  same  part  that  the 
sling  does  for  men  affected  with  orchitis.  The  idea  of  supporting  the 
abdomen  is  good  :  the  best  belt  is  that  of  Bourjeaurd  with  or  without 
the  air  cushion  according  to  the  indication.  Strict  diet  should  be  ob- 
served during  the  acute  stage,  and  even  in  the  transition  stage  great 
prudence  should  be  exercised.  In  the  chronic  form,  on  the  contrary, 
the  diet  should  be  very  nourishing,  though  light  and  digestible,  so 
that  the  patient  may  regain  flesh  and  strength.  Emollients  should  be 
applied  in  every  form  :  linseed  poultices  to  the  abdomen,  fomentations 
of  decoction  of  marshmallow  or  poppy-heads,  and  when  these  are  not 
tolerated^  embrocations  of  camphorated  oil ;  enemata  of  the  decoc- 
tion of  marshmallow,  linseed,  poppy-heads,  starch  or  oil ;  prolonged 
tepid  baths  as  soon  as  they  can  be  borne,  repeated  daily  in  the 
acute  stage,  twice  or  thrice  a  week  in  the  chronic  form,  vaginal 
injections  being  made  all  the  time  of  the  bath.  Yaginal  injections 
should  also  be  made  on  the  bidet  with  starch  and  water,  and  in 
some  cases  poultices  in  muslin  bags  should  be  introduced  as  far  as 
possible  into  the  vagina ;  they  may  be  made  of  linseed,  funis 
crispus  (Lelievre^s  instantaneous  cataplasm),  &c. :  such  are  the  dif- 
ferent ways  of  employing  emollients  concurrently  with  antiphlogistic 
treatment. 

In  acute  perimetritis,  as  in  peritonitis,  rest  should  be  ensured  to  the 
intestines  and  pain  alleviated  by  the  use  of  narcotics,  especially  opium. 
One  of  the  great  uses  of  opium  is  to  put  a  stop  to  the  stimulation 
produced  by  pain  which  is  a  continual  cause  of  fluxion  (uli  stimulus 
ibijluxus),  and  thus  two  elements  of  the  inflammation  are  subdued 
simultaneously.  It  is  useful  also  in  suppressing  alvine  evacuations 
and  of  giving  absolute  rest  to  the  intestine,  which  is  so  necessary  in 
alleviating  the  inflammatory  phenomena :  when  required,  laxative 
enemata  should  be  administered  previously,  by  means  of  a  large  rectal 
or  oesophageal  sound  introduced  far  enough  to  pass  beyond  the  tumour 
(which  often  projects  into  the  rectum  and  compresses  it),  so  that  the 
fluid  may  penetrate  into  the  colon.  After  an  evacuation  produced  by 
this  simple  means  rest  is  often  obtained  for  the  intestine.  While, 
however,  using  narcotics  to  alleviate  pain,  the  physician  should  beware 
of  mistaking  the  insensibility  produced  for  real  improvement  and  con- 
sequently of  omitting  to  prescribe  a  fresh  application  of  leeches  when 
required.  When  leeching  followed  by  the  use  of  other  means  just 
enumerated  fails  to  relieve  the  inflammatory  symptoms,  or  when  the 
weakness  of  the  patient  does  not  allow  of  bloodletting,  recourse  may 


PERI-UTERINE    INFLAMMATION  563 

be  had  to  mercurial  and  belladonna  ointment :  from  ^v  to  ^vij  of  the 
ointment  is  spread  on  a  large  compress  and  laid  on  the  abdomen ;  this 
plaster  is  better  than  frictions,  which  aggravate  the  pain.  A  thick 
layer  of  cotton  wool  should  be  laid  over  it  and  waterproof  over  all  in 
order  to  maintain  a  moist  heat  over  the  abdomen,  which  helps  the 
absorption  of  the  ointment.  The  external  application  of  mercury  may 
sometimes  be  associated  with  the  internal  use  of  calomel.  Small  doses 
of  calomel  may  be  given  combined  v^ith  jalap.  But  I  do  not  think 
that  the  intestinal  fluxion  produced  is  favorable  to  the  resolution  of 
the  inflammation  nor  that  salivation  is  desirable ;  for  even  supposing 
it  efficacious  it  is  attended  by  so  many  disadvantages  that  I  have  quite 
given  it  up. 

II.  The  second  indication  is  to  try  to  obtain  resolution  of  the  tumour 
and  of  the  liquid  and  solid  matter  which  has  been  deposited  on  the 
peritoneum.  Having  explained  how  useful  intestinal  rest  is  during 
the  acute  period,  it  is  needless  for  me  to  say  that  purgatives  should 
be  proscribed  during  this  period. 

After  bloodletting  Bernutz  recommends  that  the  whole  abdomen 
should  be  covered  with  a  camphorated  blister.  This  means  certainly 
may  be  of  great  use,  but  should  only  be  applied  in  very  serious  cases. 
Usually  blistering  is  indicated  rather  at  a  later  period.  When  resolu- 
tion commences  but  progresses  slowly  a  hypogastric  blister  is  an  excellent 
means.  We  may  then  follow  the  example  of  Piedagnel,  Nonat,  &c., 
and  powder  it  with  gr.  ^  or  gr.  |  of  hydrochlorate  of  morphia  to 
prevent  its  causing  pain.  The  blister  should  not  be  applied  at  the  time 
of  the  monthly  period,  and  its  effects  should  always  be  carefully 
watched.  It  is,  however,  in  the  transition  stage  of  the  disease  to  the 
chronic  form  and  in  the  latter  period  that  blisters  are  of  most  use ; 
they  may  be  said  indeed  to  be  the  best  means  of  causing  the  dis- 
appearance of  plastic  products.  Yelpeau  has  been  the  means  of  their 
being  largely  used  in  such  cases.  They  are  applied  after  bloodletting 
or  substituted  for  it  when  there  are  signs  of  the  formation  of  pus.  One 
may  be  applied  every  month,  a  few  days  after  menstruation;  but  if 
necessary  it  may  be  repeated  two  or  three  times  a  month,  and  should 
exceed  the  size  of  the  tumour.  They  are  applied  to  the  hypogastrium, 
to  one  or  other  of  the  iliac  fossse,  to  the  loins,  sometimes  to  the 
buttock.  They  should  be  removed  in  twenty-four  hours  and  the  serum 
evacuated,  care  being  taken  to  leave  the  epidermis  in  place.  A  thick 
layer  of  cotton- wool  should  be  applied  and  kept  in  place  by  a  bandage 
for  several  days,  as  in  the  case  of  a  burn.  Aran  boasts  of  the  efficacy 
of  blisters  applied  to  the  cervix  in  chronic  perimetritis,  but  I  confess 
that  their  use  has  always  seemed  to  me  more  suitable  in  chronic  leu- 
corrhoea  than  in  peri-uterine  inflammation.  The  cauteries,  moxas  and 
setons  proposed  by  Huguier  and  Gosselin  are  not  so  useful  as  in  the 
treatment  of  ovaritis.  The  blister  acts  on  a  larger  surface,  it  stimulates 
more  suddenly,  and  its  repeated  action  is  more  favorable  to  the  elimina- 
tion of  the  serum  and  pus  than  the  continuous  but  slow  and  moderate 
action  of  these  exutories. 

The  action  of  resolvents  and  alteratives  should  be  associated  as  soon 


564  UTERINE    DISEASES    IN    DETAIL 

as  possible  with  the  former  means.     Preparations  of  raercurj,  iodine, 
gold  and  arsenic  should  be  administered  internally,  whilst  externally 
frictions  should  be  made  daily  with  mercurial  or  iodine  ointment,  or  the 
hypogastrium  may  be  painted  with  tincture  of  iodine.^     In  such  cases, 
as  in  ovaritis,  I  have  found  small  enemata  of  resolvent  ointment  of  great 
use ;  they  are  better  than  suppositories  because  they  can  be  introduced 
farther,  they  melt  more  easily,  are  tolerated  better  and  are  more  easily 
absorbed.     The  injection  of  mercurial  ointment  per  rectum  may  be 
associated  with  painting  the  hypogastrium,  cervix  and  vagina  with 
iodine ;  or  the  application  of  mercurial  ointment  on  the  hypogastrium 
may  be  associated  with  iodide  of  potassium  per  rectum  and  tincture  of 
iodine  per  vaginam.    The  action  of  these  merdicaments  is  increased  by 
tepid  and  prolonged  alkaline  or  saline  baths,  by  the  use  of  iron,  tonics, 
generous  diet  and  residence  in  the  country,  by  the  use  of  mineral  waters 
(alkaline  and  chloride  of  sodium  waters,  such  as  those  of  Plombieres, 
Ems,  Soden),  and  at  a  later  period  by  cold  silz-baths,  cold  abdominal 
compresses,  cold  enemata — hydropathy  in  short — which  may  be  con- 
tinued for  several  months  till  the  menses  have  recurred  regularly  several 
times.     When  the  malady  is   on  the  decline  or   when  resolution  is 
effected,  mineral  waters  are  suitable  for  the  treatment  of  complica- 
tions and  for  restoring  the  strength ;  sea-bathing,  hydropathy,  sulphur 
or  iron  waters,  the  waters  of  Luchon,  Cauterets,  St.  Sauveur,  Spa, 
Plombieres,  Neris,  are  indicated.     Hydropathic  and  hydromineral  medi- 
cation is  not  merely  palliative.     It  is  the  best  adjuvant  of  resolvents. 
Purther,  these  waters  have  an  essentially  resolvent  action  of  themselves, 
in  addition  to  the  tonic,  restorative  or  sedative  action  which  they  exercise 
according  to  their  nature  or  to  the  manner  in  which  they  are  adminis- 
tered.    Only  this  action  varies  with  the  patient  and  the  period  of  the 
malady ;  it  varies  according  to  the  nature  of  the  diathetic  aflPection 
which  complicates  the  peri-uterine  inflammation ;  it  varies  also  with  the 
mineral  water  and  with  its  mode  of  administration.     Hence  another 
action  beyond  that  of  simple  absorption  of  plastic   products,  which 
leads  to  these  medicaments  being  classed  among  those  which  fulfil  the 
third  indication  in  the  treatment  of  perimetritis. 

III.  The  third  indication  is  to  treat  the  diathetic  affection  under  the 
influence  of  which  chronic  perimetritis  has  a  tendency  to  be  per- 
petuated, and  at  the  same  time  restore  the  weakened  and  deteriorated 
organism.  Pelvic  peritonitis  being  according  to  Bernutz  a  malady 
symptomatic  of  very  different  affections,  presents  very  various  thera- 
peutical indications,  not  only  according  to  its  acute  or  chronic  form, 
its  sero-adhesive  or  purulent  nature,  but  according  to  the  indications 
furnished  by  the  diathesis  of  which  the  inflammation  of  the  serous 
membrane  is  a  remote  manifestation.  Bernutz  therefore  recommends 
mercury  when  there  is  reason  to  believe  that  the  diathesis  is  syphilitic, 
turpentine  when  there  is  blennorhagia,  &c. 

^  Joannowsky  of  Prague  {Prager  Vierteljahrsclio-i'ft,  1878)  lias  proved  that 
iodine  is  absorbed  and  is  found  in  the  urine.  Out  of  30  women  treated  by- 
painting  the  hj'pogastrium,  cervix  and  vagina  with  iodine,  11  were  cured,  It 
improved. 


PEEI-UTERINE    INELAMMATION  565 

It  is  in  chronic  pelvic  peritonitis  that  the  principles  of  Beruutz  may 
be  applied.  He  recommends  the  alkaline  waters  of  Vichj  if  dyspepsia 
predominates,  hydropathy  if  the  symptoms  are  nervous,  sulphurous 
baths  if  scrofula  has  previously  existed,  arsenical  baths  if  there  is  any 
cutaneous  affection  the  result  of  scrofula,  arthritis  or  rheumatism.  The 
determination  of  the  diathesis,  to  which  the  chronicity  of  the  inflam- 
matory action  is  to  be  attributed,  deserves  the  careful  attention  of  the 
physician.  Bernutz  usually  associates  hemlock  with  this  antidiathetic 
medication.  He  considers  it  the  specific  narcotic  of  the  genital  oro-ans, 
and  increases  the  dose  till  disorders  of  vision  and  hallucinations  are 
produced.  He  is  not,  however,  sure  of  its  efficacy.  As  to  iodide  of 
potassium,  I  do  not  see  that  its  administration  is  contra-indicated,  as 
he  says,  by  the  necessity  of  feeding  up  patients. 

IV.  The  complications  which  coexist  with  perimetritis  or  which 
persist  after  its  cure  must  also  be  treated.  Vomiting  is  one  of  the  first 
complications  which  may  require  treatment,  for  it  is  symptomatic  of 
peritonitis.  It  appears  at  the  most  acute  period  of  the  disease  and 
returns  with  every  exacerbation.  In  order  to  stop  it  nothing  should  be 
taken  but  fragments  of  ice  from  time  to  time  or  a  little  iced  cham- 
pagne, lemonade  or  soda  water ;  sedatives  should  be  given  externally 
and  internally,  opium,  belladonna,  chloroform,  a  blister  powdered  with 
hydrochlorate  of  morphia  on  the  epigastrium,  nux  vomica  or  strychnia 
in  small  doses  or  subnitrate  of  bismuth.  One  of  the  best  preparations 
is  the  following:  Pulv.  Eadic.  Caiumb.,  Calc.  Carb.  prep,  aa  gr.  1^  to 
gr.  3;  Pulv.  Bellad.  Eadic.  gr.  -^V  to  gr.  i  mixed  and  given  in  a 
spoonful  of  iced  water,  and  repeated  every  four  hours  or  oftener  if 
necessary.  The  distension  of  the  belly  which  often  occurs  with 
vomiting  should  be  treated  with  poultices  sprinkled  with  camphor- 
ated oil  or  with  iced  compresses.  Constipation  necessitates  the 
administration  of  simple  or  laxative  enemata  introduced  by  a  thick 
and  long  cannula  ;  mild  laxatives  may  be  given  by  the  mouth  in  the 
chronic  period,  and  in  the  absence  of  acute  pain  in  the  belly.  When 
it  does  not  yield  to  these  means,  cold  ascending  douches  should 
be  prescribed  or  pills  containing  from  gr.  |  each  of  the  extract 
and  powder  of  bellad.  and  gr.  ^^^  of  strychnia,  a  little  sulphate 
of  zinc,  or  even  a  little  aloes  with  great  prudence.  If  diarrhoea 
occurs,  it  should  be  treated  with  bismuth  or  opium,  giving  from 
gr.  3  to  gr.  4-^  in  the  day,  care  being  taken  to  give  it  in  small 
doses  at  a  time.  Small  enemata  may  also  be  given  containing  a 
little  laudanum  or  nitrate  of  silver  in  the  proportion  of  gr.  3  to  gr.  6 
in  ^iij  of  water. 

Pain  and  neuralgia  are  the  most  frequent  complications  during  and 
after  the  malady.  I  have  already  explained  how  the  pains  of  acute 
perimetritis  should  be  subdued  by  large  doses  of  opium  which  also 
ensure  the  rest  so  necessary  to  the  viscera.  Anodyne  fomentations 
should  be  applied  simultaneously  with  the  same  object.  Bernutz 
recommends  a  bath  every  three  or  four  days,  and  from  5  to  7  grains 
of  powdered  hemlock  every  day.  Wlien  pain  occurs  suddenly  in  the 
loins  or  belly  during  chronic  perimetritis,  it  is  usually  the  sign  of  aa 


566  UTEEINE  DISEASES    IN    DETAIL 

exacerbation  :  one  of  the  best  means  of  dissipating  it  is  to  leech  the 
cervix  and  then  apply  a  blister  to  the  abdomen  or  rub  with  croton  oil, 
care  being  taken  to  cover  the  part  afterwards  with  adhesive  plaster  to 
prevent  pain  being  produced  by  contact  with  the  clothes.  When  pain 
continues  and  uterine  or  peri-uterine  hyperaesthesia  also  exist,  Aran's 
application  of  laudanum  may  be  tried,  which  consists  in  pouring  a 
little  into  the  vagina  by  means  of  a  speculum  and  then  applying  a 
tampon.  In  place  of  simple  pain,  there  is  often  neuralgia,  even  at  the 
commencement  of  the  disease  in  hysterical  patients,  but  generally  at 
the  end.  This  neuralgia  is  best  subdued  by  the  application  of  a 
small  ammoniated  blister  to  the  painful  part,  which  must  be  after- 
wards dressed  every  day  with  hydrochlorate  of  morphia,  or  by  sub- 
cutaneous injections  of  this  salt.  Lastly,  as  the  final  treatment  of 
the  nervous  symptoms  which  persist  after  pelvic  peritonitis,  recourse 
should  be  had  to  hydropathy  and  to  residence  in  the  country, 
as  the  best  adjuvants  of  narcotics,  faradisation,  the  continuous  cur- 
rent, &c. 

There  may  be  haemorrhage  in  chronic  perimetritis  though  this 
seldom  occurs  ;  when  it  does,  hemostatics  should  be  administered, 
such  as  lemonade,  mineral  acids,  rhatany,  cold  or  acid  applications  to 
the  hypogastrium,  or  on  the  contrary  very  hot  injections;  sometimes  a 
blister  on  the  iliac  fossa  stops  the  flow.  Ergot  should  never  be 
employed  in  such  cases.  As  for  the  other  comphcations,  metritis, 
nterine  catarrh,  leucorrhcea,  vulval  pruritus,  deviations,  &c.,  they  are 
ameliorated  by  the  treatment  of  perimetritis,  but  should  not  be 
attacked  directly  till  after  the  peri-uterine  inflammation  has  been 
cured. ^ 

Y.  The  opening  of  the  purulent  collection.  In  the  case  of  acute 
pelvic  peritonitis  puncture  may  be  made  through  the  vagina.  This 
often  simplifies  the  malady  and  hastens  cure  as  in  cases  of  acute 
pleurisy  with  effusion;  but  as  it  is  attended  with  some  risk  it  is 
usually  preferable  to  wait  the  formation  of  pus.  Even  when  pus  is 
formed,  opinions  are  divided  as  to  whether  the  abscess  should  be 
opened.  Bourdon  ^  is  in  favour  of  the  artificial  opening  of  pelvic  as 
of  all  other  abscesses ;  he  says  "  the  presence  of  pus  facilitates  its 
formation ;  the  tumour  may  be  very  large  and  the  pus  may  travel  a 
long  way  producing  irreparable  mischief;  the  abscess  finding  no 
external  outlet  may  be  discharged  into  the  peritoneum ;  and  if  the 
opening  occurs  spontaneously  or  is  made  late,  patients  are  condemned 
to  sufferings  which  they  might  have  been  spared ;  it  may  also  open  at 
an  unfavorable  point  for  the  discharge  of  pus;  and  lastly,  in  many 
cases  the  patient  being  greatly  enfeebled  by  a  long  malady  is  no 
longer  in  a  favorable  condition  for  recovery  after  the  opening  of  the 
abscess,  even  in  the  absence  of  interminable  fistulas  and  suppurations.'" 
Nonat  also  insists  on  the  necessity  of  opening  abscesses  :  the  presence 
of  pus  may  cause  peritonitis,  even  phlebitis  with  general  disorders  and 

^  Piotowsky  {Bu  catarrhe  iderin  d^xns  la  pelvi-peritonite  et  de  son  traite- 
ment)  places  beyond  doubt  the  dangei-s  attending  too  hasty  intervention. 
'  Tumeurs  jiuctuantes  du  petit  hassin  {Revue  medicale,  1841). 


PEEI-UTERINE    INFLAMMATION  567 

perforations  which  may  be  fatal.  Bernutz  also  recommends  artificial 
opening  as  soon  as  symptoms  of  hectic  fever  have  succeeded  the  acci- 
dents of  acute  pelvic  peritonitis. 

Aran  on  the  contrary  thinks  that  pelvic  abscesses  should  seldom  be 
opened  artificially  :  he  says  that  the  pus  being  imprisoned  in  a  kind  of 
cyst  formed  by  false  membranes  does  not  spread;  an  artificial  opening 
does  not  prevent  a  natural  opening  occurring  at  an  unfavorable  point 
for  the  evacuation  of  pus ;  hectic  fever  may  follow  the  one  as  well  as 
the  other ;  lastly^  the  pus  may  possibly  be  absorbed  and  the  malady  be 
cured  without  any  opening  either  natural  or  artificial  as  occurred  in 
cases  described  by  Aran  and  Marchal  de  Calvi.  It  is  therefore 
prudent  he  thinks  to  abandon  the  opening  of  pelvic  abscesses  to 
nature.  I  think,  however,  that  these  reasons  are  exaggerated.  On 
the  one  hand,  the  origin  of  abscesses  should  be  taken  into  account ; 
expectation  is  more  indicated  in  those  produced  by  pelvic  peritonitis 
(which  is  usually  encysted),  artificial  opening  for  those  resulting  from 
a  phlegmon  of  the  broad  ligaments,  as  it  has  a  tendency  to  spread. 
On  the  other  hand,  whatever  be  the  origin,  though  pelvic  abscesses 
may  not  always  be  in  conditions  to  be  opened  early,  as  happens  in 
other  purulent  collections,  I  think  it  is  dangerous  to  wait  too  long. 
If  the  abscess  reacts  on  the  economy,  if  the  presence  of  pus  causes 
hectic  fever,  if  the  tumour  raising  the  abdomen  seems  to  adhere  to  it 
or  to  project  towards  the  vagina  or  rectum,  if  the  walls  have  become 
thin  announcing  imminent  rupture,  if  the  abscess  has  opened  at  an 
unfavorable  point  for  the  complete  evacuation  of  the  pus,  if  the  urine 
or  fsecal  matter  accumulates  in  the  sac  the  abscess  should  be  opened 
artificially. 

When  the  abscess  is  subtegumentary  it  should  be  opened  through 
the  abdominal  wall.  When  it  is  very  superficial  and  points  to  the 
surface  of  the  abdomen,  and  when  there  is  reason  to  hope  that  adhe- 
sions are  established  between  the  visceral  and  parietal  peritoneum  the 
bistoury  may  be  used ;  in  doubtful  cases  the  bistoury  should  only  be 
used  according  to  the  method  of  Graves,  who  reaches  the  peritoneum 
without  opening  it,  or  according  to  that  of  Begin,  who  incises  the 
parietal  peritoneum  without  touching  the  tumour.  As  a  rule,  how- 
ever, the  use  of  caustics  is  preferable,  all  the  more  so  that  by  arousing 
the  vitality  of  the  tissues  and  producing  a  salutary  derivation  they  may 
exceptionally  bring  about  the  absorption  of  pus.  In  employing  them 
the  rules  laid  down  by  Recamier  for  the  opening  of  liquid  tumours  of 
the  liver  should  be  observed,  or  those  of  Martin^  for  the  opening  of 
deposits  of  the  annexes  occurring  after  delivery,  that  is  to  say,  succes- 
sive applications  of  caustic  potash  should  be  made  at  the  same  point 
from  without  inwards.  Vienna  paste  is  better  still :  the  scar  should 
be  incised  and  excised  daily  and  a  fresh  appHcation  of  the  caustic 
made  so  that  adhesions  may  be  established  all  round  the  opening  after 
the  abscess  is  reached.  If  the  opening  remains  fistulous  too  long 
there  is  no  danger  in  cautiously  trying  antiseptic  and  iodine  injections. 

1  Memoires  de  med.  et  de  chir.  prat.,  p.  312.  Paris,  1835. 


568  UTERINE    DISEASES    IN    DETAIL 

Bertrand^  cured  an  abscess  in  this  way,  tlie  pus  from  whicli  was  eva- 
cuated by  the  navel  after  puerperal  metro-peritonitis  lasting  for  six 
months.  We  know  of  cases  of  definite  cure  due  to  pregnancy,  proba- 
bly owing  to  the  compression  and  adhesion  of  the  walls  of  the  abscess. 
Why  then  not  imitate  nature,  taking  care  to  exercise  methodic  com- 
pression of  the  hypogastrium,  after  the  pus  has  been  evacuated,  with 
Bourjeaurd's  belt?  I  have  seen  methodic  compression  do  so  much 
good  in  cases  of  iliac  abscess  and  of  enormous  abscesses  in  the  hips 
that  I  have  no  doubt  as  to  the  efficacy  of  this  means  when  applied  to 
the  cure  of  pelvic  abscesses.  Lister^s  antiseptic  treatment  should  also 
be  carefully  carried  out. 

When  the  abscess  points  towards  the  vagina  or  rectum  it  should  be 
opened  there.  Openiag  by  the  vagina  is  easier  and  more  favorable, 
and  therefore  should  always  be  preferred  when  possible.  According 
to  Bernutz,  a  curved  trocar  can  when  necessary  be  introduced  by  one 
of  the  iliac  fossae  passing  thence  into  the  vagina.  This  method  has 
been  employed  by  Koeberle  after  ovariotomies  giving  rise  to  an  accu- 
mulation of  pus  in  the  vagino-rectal  cul-de-sac,  and  by  Pean,^  who  has 
invented  a  curved  trocar  for  perforating  the  posterior  vaginal  cul-de-sac 
from  above  downwards;  it  is  introduced  by  a  small  incision  in  the 
abdominal  wall  above  the  crural  arch  near  the  border  of  the  uterus. 
In  such  cases  I  have  introduced  a  long  curved  trocar  (such  as  is  used 
in  puncturing  the  bladder  by  the  rectum  in  men)  behind  the  uterus, 
by  means  of  which  I  have  perforated  the  retro-uterine  cul-de-sac  and 
passed  a  drainage  tube  into  the  wound.  In  such  cases  caustics  cannot 
be  used ;  the  bistoury  is  introduced,  with  or  without  the  speculum  to 
the  dependent  part,  or  to  the  most  projecting  portion  of  the  tumour. 
When  Eergusson's  speculum  cannot  be  used  Sims's  should  be  tried,  or 
the  labia  and  vaginal  walls  may  be  kept  apart  by  the  fingers  of  assis- 
tants or  by  the  instruments  invented  by  Jobert  for  the  operation  of 
vesico-vaginal  fistula.  Eecamier  used  a  pharyngotome  or  a  silver  bis- 
toury.^ Blandin^s  or  any  other  concealed  bistoury  can  be  employed.  , 
However  an  ordinary  straight  bistoury  will  serve  the  purpose;  its 
blade  should  be  covered  with  linen  or  diachylon  plaster  to  within  half 
an  inch  of  the  point  and  introduced  flat  on  the  index  finger  till  the 
most  projecting  and  resistant  portion  of  the  tumour  is  reached  and 
pierced,  moderate  pressure  being  used  till  we  feel  that  resistance  has 
been  overcome  and  that  pus  is  being  discharged.  Large  openings 
should  not  be  made  for  fear  of  hsemorrhage,  for  the  flow  of  blood  is 
often  considerable  even  when  a  vertical  direction  has  been  given  to  the 
incision  according  to  Recamier's  advice.  The  best  instrument  of  all 
is  the  fine  aspirator  trocar ;  it  is  introduced  like  the  bistoury  on  the 
index  finger  of  the  left  hand ;  we  make  sure  that  it  has  entered  the 
cavity  of  the  abscess  by  withdrawing  the  stylet,  and  if  the  pus  is  not 
discharged  easily  the  opening  is  enlarged.     Usually  there  is  not  much 

*  Bulletin  de  la  8ocietedemed.de  Besangon,  1858. —  Gazette  med.  de  Paris, 
1860,  p.  430. 
^  Ovariotomie  et  splenotomie,  p.  21.  Paris,  1869. 
^  H.  Bourdon,  Mem.  cit.,  p.  71. 


LEUOOEIiHCEA    AND    UTEEINE    CATAKRH  569 

pus,  and  it  is  quite  exceptional  for  the  sac  to  fill  again  and  again  and  to 
persist  in  the  fistulous  state.  Hence  the  uselessness  of  a  second  punc- 
ture ;  it  would  be  better  to  discover  the  purulent  collections  of  the 
ovary  and  Fallopian  tube,  which  are  situated  frequently  in  the  centre 
of  the  abscess,  and  evacuate  their  contents ;  unfortunately  it  is  very 
difiicult.  After  puncture  it  is  unnecessary  to  leave  the  cannula  of  the 
trocar  in  the  opening ;  or  even  to  introduce  a  gum-elastic  sound  as 
Laugier  did  after  puncturing  a  peri-uterine  hematocele,  or  a  tent, 
because  there  is  not  always  pus  to  be  discharged,  and  all  these  foreign 
bodies  touch  the  peritoneum  and  consequently  may  become  very 
dangerous. 

After  puncture  perfect  rest  should  be  enjoined  and  emollient 
enemata  and  cataplasms  prescribed.  That  improvement  may  be  lasting- 
inflammation  must  be  entirely  extinguished  :  many  cures  are  then  ob- 
tained, as  mentioned  by  Bourdon  in  his  paper.  A  strict  diet,  how- 
ever, should  not  be  enforced  for  long.  On  the  contrary,  tonics,  bitters, 
quinine  and  iron  should  be  given.  Lastly,  we  hold  ourselves  in 
readiness  for  the  approaching  monthly  period  when  there  will  be  a 
recurrence  of  pelvic  pain  and  inflammation. 


Of  Leucorrhcea  in  General  and  Uterine  Catarrh  in 
Particular 

Leucorrhcea  is  a  pathological  discharge  produced  by  the  increase 
and  alteration  of  the  normal  secretions  of  the  genital  economy.  This 
name,  which  literally  means  white  discharge  [XevKog  white,  puv  to 
flow),  is  commonly  used  to  denote  all  discharges  except  that  of 
blood,  depending  on  diseases  of  various  nature,  excreted  by  different 
organs,  being  less  a  special  malady  than  a  symptom  common  to  several 
diseases.  The  progress  of  medicine  with  regard  to  this  has  been 
checked  for  long  by  a  feeling  of  modesty  on  the  part  of  women ;  for  a 
great  number  refrain  from  telling  their  physician  of  these  discharges, 
whilst  others  inform  him  of  the  fact,  but  refuse  to  submit  to  an 
examination.  Now  there  is  as  much  difference  between  the  various 
kinds  of  white  discharges  as  there  is  between  various  kinds  of  expecto- 
ration. 

We  shall  give  the  name  of  false  leucorrkoea  to  fluid  discharges  of 
various  kinds  issuing  from  the  genital  organs,  reserving  that  of  leucor- 
rhcea to  those  produced  directly  by  these  organs  under  the  influence  of 
a  very  characteristic  pathological  condition. 

I.  False  leucorrhcea. — This  may  be  occasioned  by  the  presence  of 
foreign  bodies  or  by  the  development  of  more  or  less  serious  organic 
lesions.  A  foreign  body,  such  as  a  pessary,  remaining  in  the  vagina 
or  in  the  uterus  produces  inflammation,  hypersecretion  and  suppura- 
tion, retaining  purulent  fluids  which  in  decomposing  exhale  a  pene- 
trating odour  of  acid  fermentation.  Hydatidiform  or  fleshy  moles, 
polypi,  fibroid  tumours,  produce  discharges  resulting  from  the  irrita- 


570  UTEEINE    DISEASES   IN    DETAIL 

tion  produced  by  their  presence  on  the  uterine  mucous  membrane  and 
especially  on  its  glands.  Abscesses  of  the  uterus  or  extensive  sup- 
puration of  the  whole  internal  surface  of  the  organ  may  determine  the 
intermittent  or  continuous  discharge  of  quantities  of  pus,  which  are 
seen  in  such  cases  to  issue  from  the  uterine  cavity  itself.  Ashwell 
has  seen  half  a  pint  of  pus  discharged  from  this  cavity,  and  Saflbrd- 
Lee  once  saw  an  abundant  purulent  discharge  produced  by  the  presence 
of  a  polypus  (referred  to  by  Graily  Hewitt,  p.  86).  Matthews  Duncan^ 
describes  the  case  of  an  old  woman  who  had  ceased  to  menstruate, 
and  who  had  a  considerable  discharge  of  pus  from  the  uterine  cavity ; 
I  have  seen  a  similar  case  j  and  another  in  which  an  interstitial  abscess 
opened  on  the  anterior  lip  of  the  cervix.  Uterine  tuberculisation, 
which  however  is  rare,  may  also  determine  an  aqueous,  dirty  yellow  or 
pale  brown  discharge.  Cancer  produces  a  serous  or  sero-sanguineous 
discharge  like  reddish  water,  sometimes  acrid  and  irritating  to  the  sub- 
jacent tissues,  seldom  inodorous,  usually  foetid.  Lastly,  the  evacuation 
of  an  ovarian  cyst  by  the  Fallopian  tube  may  cause  a  discharge  which 
may  be  confounded  with  leucorrhoea. 

II.  Leucorrhoea  properly  so  called. — Leucorrhoea,  like  the  white 
discharges  just  enumerated,  is  usually  symptomatic ;  indeed  it  is  only 
by  an  abuse  of  language  that  leucorrhoea  can  be  called  idiopathic. 
Nevertheless  I  think  it  is  well  to  keep  the  name  and  give  the  patho- 
logical description  of  leucorrhoea  for  several  reasons.  The  first  is  the 
interest  presented  by  leucorrhoea  in  uterine  semeiology.  The  second 
is  the  importance  of  this  sjmptom  with  regard  to  indications.  In  order 
to  judge  of  the  existence,  intensity,  seat  and  nature  of  leucorrhoea,  we 
must  first  of  all  learn  to  recognise  the  leucorrhmal  products. 

The  normal  secretions  of  the  vulva,  vagina  and  uterus  differ  from 
each  other  just  as  do  the  membranes  from  which  they  are  produced. 

Vulval  mucus  is  viscous,  slightly  adherent  to  the  fingers  when 
touched,  becoming  thready  when  the  latter  are  slightly  separated. 
That  of  the  vulvo-vaginal  glands  resembles  greatly  that  of  Cowper's 
glands  in  man.  It  gives  an  acid  reaction.  The  mucus  of  the  ves- 
tibular and  peri-urethral  follicles  has  always  seemed  to  me  more  acid 
than  that  of  the  vulvo-vaginal  glands.  When  mixed  with  the  seba- 
ceous secretion  it  often  forms  a  kind  of  magma  with  a  cheesy  smell  or 
rather  a  smell  of  sour  and  fermented  cheese.  Sometimes,  although  in 
immediate  contact,  the  two  products  do  not  mix. 

The  vaginal  fluid,  to  which  the  name  of  mucus  should  perhaps 
not  be  given,  cannot  apparently  be  produced  in  such  abundance  as  the 
mucus  of  the  vulva  and  uterus,  at  least  not  in  the  normal  condition. 
It  is  a  clear,  transparent,  serous  fluid,  having  no  viscosity,  but  seldom 
seen  alone,  for  apparently  it  is  only  the  vehicle  of  innumerable  broad, 
lamelliform  corpuscles  which  are  detached  continuously  by  exfoliation 
and  in  more  or  less  considerable  quantity  from  the  surface  of  the 
mucous  membrane,  giving  to  the  excretion  the  white,  opaque,  cheesy 
aspect  which  characterises  it.     The  vaginal  excretion  therefore  is  in 

1  Edin.  Med.  Journal,  March,  1868. 


LEUCOEEH(EA   AND   UTERINE    CATARRH 


571 


factj  as  described  by  Donne/  a  thick  creamy  fluid,  never  glutinous  like 
that  from  the  uterus,  acid  and  containing  cells  of  pavement  epithelium 
four  or  five  hundredths  of  a  millimetre  in  diameter.  This  mucus  is 
acid,  whilst  that  from  the  uterus  is  alkaline ;  both  contain  globules 
of  pus  in  proportion  as  the  mucus  is  diseased ;  their  colour  is  more 
or  less  modified  according  to  the  quantity  of  these  anatomical 
elements. 

The  uterine  mucus  is  quite  different  from  the  vaginal  fluid.  It  is 
more  like  vulval  mucus,  although  distinguished  from  the  latter  by  its 
physical  characters  and  by  its  mode  of  excretion.  We  must,  however, 
remember  that  the  name  uterine  mucus  includes  two  very  different 
kinds  of  mucus  :  that  of  the  cervix  and  that  of  the  fundus.  Both  are 
limpid  normally,  and  the  secretion  is  so  scanty  when  the  organ  is  at 


Fig.  329. — Vaginal  pavement  epithelium  covering  the  mucous  membrane  of 
the  cervix.     240  diameters  (Tyler  Smith). 

rest  that  when  examining  with  the  speculum  a  woman  whose  uterus  is 
normal  not  only  is  there  no  discharge  to  be  seen,  but  not  even  a  single 
drop  can  be  forced  to  exude  by  pressing  the  cervix  with  the  instru- 
ment. Both  may  appear  at  the  uterine  orifice  in  the  form  of  a  drop  of 
thin  transparent  fluid  spreading  from  the  orifice  to  the  lower  lip  of 
the  cervix,  increasing  in  quantity  by  pressure,  but  remaining  adherent 
to  the  organ,  from  which  there  is  usually  some  difficulty  in  detaching 
it  entirely  even  by  wiping  with  cotton-wool.  In  this  mixed  fluid  there 
is  usually  more  mucus  from  the  cervix  than  from  the  fundus ;  but  the 
mixture  may  be  so  equal  that  it  is  difficult  to  distinguish  them.  Some- 
times their  different  characteristics  are  recognised  at  once  by  the 
absence  of  one  or  other  secretion ;  sometimes  the  cervix  is  obstructed 
by  its  own  secretion;  sometimes  it  does  not  apparently  secrete  mucus, 
but  after  the  sound  has  been  used  a  fluid  is  seen  to  exude  which  really 
comes  from  the  body,  or  the  hollow  sound  brings  with  it  a  portion  of 
this  fluid,  the  special  characters  of  which  may  then  be  distinguished. 
Both  are  transparent  and  limpid,  and  if,  as  some  observers  aflirm,  that 
of  the  cervix  is  yellowish  and  that  of  the  body  semi-transparent  and 
greyish,  it  is  owing  I  think  to  some  slight  disorder  of  the  secretion.    I 

*  Cours  de  microscojne  complcmentaire  des  etudes  medicales,  p.  155.  Paris 
1844. 


572 


UTERINE    DISEASES    IN    DETAIL 


have  never  observed  such  differences  in  the  normal  state.  Both  have 
a  peculiar  stale  odour,  which  may  be  strong  in  different  diseases  and 
after  delivery  or  puerperal  fever,  but  which  is  never  acid;  both,  on 


nwr^'i^ 


4.1 


Fig.  331,— Cylindrical  epithe- 
lium with  vibratile  cilia 
from  the  cavity  of  the  body 
of  the  uterus.  220  diame- 
ters (Tyler  Smith). 


Fig.  330. — Normal  mucous  secretion  from 
the  cervix,  extracted  from  its  mucous 
follicles.  The  mucous  corpuscles  ai'e 
ranged  in  longitudinal  series  owing 
to  the  viscosity  of  the  fluid  in  which 
they  are  entangled.  220  diameters 
(Tyler  Smith). 

the  contrary,  are  always  alkaline.  As  to  their  distinguishing  charac- 
teristics, that  of  the  cervix  is  gluey,  tenacious,  half  solid  rather  than 
liquid ;  hypersecretion  of  it  is  frequent ;  mucous  corpuscles,  cells  of 
nucleated  epithelium,  are  more  or  less  abundant  in  the  transparent  and 
granular  fluid.  During  pregnancy  it  is  produced  in  considerable 
quantity,  and  is  then  more  glutinous,  more  tenacious  still  than  in  the 
state  of  vacuity,  and  it  plugs  the  cervix  {houchon  gelatineux) .  It  does 
not  hold  any  other  anatomical  element  in  suspension  except  the  nucleated 
cells ;  it  is  entirely  homogeneous.  That  from  the  body  is  viscous,  less 
tenacious  than  that  from  the  cervix;  it  contains  numerous  epithelial 
globules,  ovoid  nuclei,  coming  from  the  flexuous  follicles  of  the  mucous 
membrane,  prismatic  epithelial  cells  or  cylindrical  and  vibratile  cells 
from  the  surface  of  this  mucous  membrane,  sometimes  granular  bodies 
of  inflammation.  The  relatively  large  number  of  these  solid  elements 
mixed  with  the  secreted  fluid  sometimes  alters  its  transparency,  giving 
it  the  grey  tint  of  which  I  have  just  spoken.  This  distinction  is  all 
the  more  important  as  uterine  leucorrhcea  is  often  limited  to  the 
cervical  mucous  membrane. 

To  sum  up,  this.mucous  surface,  which  was  long  regarded  as  iden- 
tical  in    all    its    parts,   secretes    mucus,   the    physical    and   chemical 


LEUOOREHCEA   AND    UTERINE    CATARRH  573 

characters  of  which  are  very  different.  If  these  differences  have  not 
been  observed  sooner,  it  is  because  the  speculum  has  only  been  used 
during  the  last  fifty  years,  because  the  utero-vaginal  secretions  were 
often  altered  or  mixed  in  cases  where  the  introduction  of  the  speculum 
would  have  allowed  them  to  be  distinguished,  because  the  attention  of 
the  physician  was  not  directed  to  searching  for  differences  between 
fluids  coming  from  mucous  membranes  the  anatomical  structure  of 
which  was  supposed  to  be  similar,  and  lastly,  because  in  other  cases  in 
which  it  was  a  question  of  diseases  not  accompanied  by  discharges, 
or  in  which  the  genital  organs,  the  uterus  especially,  were  in  normal 
health,  secretions  were  not  observed. 

III.  Idiojmtkic  leitcorrkixa  is  an  abnormal  discharge  from  the 
mucous  membranes  of  the  genitals,  more  especially  from  the  uterus ; 
it  is  mucous  or  muco-purulent,  favoured  by  general  atony  and  by  a 
local  predisposition,  and  filially  determined  by  a  slight  irritation  of  the 
secreting  membrane  or  by  a  functional  imperfection,  such  as  chlorosis. 
It  constitutes  a  special  morbid  condition  or  an  essential  malady,  the 
same  as  any  other  fluxion  such  as  diarrhoea,  bronchorrhoea,  urethral 
blennorrhoea,  sialorrlicea,  profuse  sweating,  &c.  Amongst  other  condi- 
tions of  general  atony  which  predispose  to  leucorrhcea,  we  may  men- 
tion age,  temperament,  constitution,  climate,  food,  &c.  It  is  difficult, 
however,  to  appreciate  the  influence  of  these  various  causes.  It  is 
said  that  feeble  constitutions  and  lymphatic  temperaments  are  subject 
to  leucorrhoea,  which  I  think  is  true  in  spite  of  the  contrary  assertion 
made  by  some  pathologists  who  have  probably  observed  cases  of 
simultaneous  blennorrhagia,  vaginitis  and  leucorrhcea  in  prostitutes, 
and  who  have  made  these  the  basis  of  their  statistics.  I  think  it  is 
more  commonly  met  with  in  young  women  than  in  old ;  I  have  seen 
it  in  girls  after  the  appearance  of  the  catamenia.  Cold  and  damp 
climates  also  predispose  to  it.  It  has  been  said  that  warm  climates 
relax  the  vessels  and  prepare  the  way  for  fluxions  and  hsemorrhages, 
but  as  a  matter  of  fact  it  has  been  proved  that  damp  countries,  such 
as  Belgium,  Holland,  and  the  marshy  districts  of  England  do  so  much 
more.-^  According  to  statistics  made  in  Paris  by  Marc-Despine,  and 
in  Marseilles  by  Girard,  two  thirds  of  the  women  in  Paris  suffer  from 
leucorrhoea,  whilst  only  one  fourth  of  the  Marseilles  women  do.^ 
Residence  in  towns  is  generally  considered  as  favorable  to  leucor- 
rhoea, and  this  opinion  is  confirmed  by  the  researches  made  by  Brierre 
de  Boismont.^  Lastly,  a  poor  diet  is  one  of  the  most  powerfully  pre- 
disposing causes ;  it  is  on  this  account  that  the  use  of  coffee  has  been 
blamed,  but  wrongly  so,  for  when  pure  it  is  very  wholesome.  To 
these  causes  of  general  debility  we  may  add  the  more  special  ones 
which  act  in  the  same  direction :  prolonged  lactation  in  weak  nurses, 
cardiac  disease,  chronic  pulmonary  disease,  emphysema,  tendency  to 

^  Graily  Hewitt,  op.  cit.,  p.  89. 

^  Marc  Despine,  Recherches  anatomiques  sur  quelques  points  de  Vhlstoire 
de  la  Heucorrhee,  in  Archives  generales  de  medecine,  2*  sei-ies,  t.  x,  p.  105. 
Paris,  1836. 

^  De  la  menstruation  consider ee  dans  ses  rapports  pi bysiologiques  ct  patliolo- 
giques,  ch.  xiii,  Desjlueurs  blanches,  p.  259.  Paris,  18X2. 


574  UTERINE    DISEASES    IN    DETAIL 

phthisis  and  phthisis  itself^  lastly  the  various  diatheses  of  which  leu- 
corrhoea  is  not  always  symptomatic  but  which  prepare  the  organism 
for  it  by  the  debility  into  which  they  throw  it.  To  this  I  think  we 
may  add  a  local  predisposition,  consisting  in  a  special  atony  of  the 
genital  economy  or  of  one  of  its  organs.  I  have  often  observed  that 
leucorrhceic  women  were  pale,  flabby,  the  vulvo-vaginal  mucous  mem- 
brane being  very  extensible,  the  follicular  or  glandular  orifices  open, 
that  there  were  symptoms  of  passive  hypersemia,  prolapsus  or  flexion 
of  the  uterus,  relaxation  of  its  ligaments,  frequent  involuntary  excre- 
tion of  urine  caused  by  laughter  or  some  other  effort,  sometimes  even 
nocturnal  incontinence  of  urine.  In  women  who  have  these  predispo- 
sitions, leucorrhoea  may  be  determined  by  two  causes  of  different  kinds 
which  it  is  important  to  diagnose  in  order  to  seize  the  indications  of 
treatment.  Sometimes  a  slight  local  irritation  suffices  to  produce  the 
discharge  which  is  afterwards  kept  up  all  the  more  easily  because  the 
patient  is  in  a  sense  prepared  for  it.  Venereal  excitement,  excessive 
coitus,  menstruation,  pregnancy,  abortion,  delivery  are  the  most  com- 
mon causes.  These  same  causes  acting  energetically  and  continuously 
may  produce  inflammation  of  the  vulva,  vagina  or  uterus ;  but  usually 
their  action  is  limited  to  the  production  of  leucorrhoea.  The  approach 
of  puberty,  the  slight  excitement  which  precedes  and  follows  every 
monthly  period,  are  often  marked  by  the  whites.  Pregnancy,  under 
the  influence  of  the  fluxion  and  congestion  which  it  keeps  up  in  the 
genital  mucous  membrane  often  develops  vaginal  leucorrhoea.  The 
simple  congestion  which  it  may  leave  in  the  organs,  the  slow  retro- 
grade evolution  of  the  uterus,  are  often  the  starting-point  of  a  leucor- 
rhoeic  fluxion  which  may  be  prolonged  indefinitely. 

Sometimes  a  functional  imperfection  of  the  uterus  or  the  reaction  on 
this  organ  of  the  functional  disorder  of  another  organ  may  be  the  origin 
of  leucorrhoea.  In  chlorotic  and  amenorrhoeic  girls  it  seems  that  from 
some  alteration  of  the  blood  such  as  general  debility  or  atony  of  the  san- 
guineous vessels  of  the  uterus,  the  periodical  fluxion  of  this  organ  is 
insufficient  to  produce  haemorrhage ;  it  terminates  in  a  simple  mucous, 
sero-mucous,  muco- sanguineous  or  muco-purulent  fluxion.  This  dis- 
charge sometimes  only  appears  at  the  monthly  period,  sometimes  it  is 
repeated  in  the  interval.  At  other  times  it  is  continuous  but  usually 
increases  at  the  time  corresponding  to  the  monthly  period,  decreasing 
afterwards.  I  have  often  seen  all  these  varieties.  This  discharge  some- 
times undoubtedly  contains  globules  of  pus,  indicative  of  a  slight  irrita- 
tion of  the  surface  of  the  mucous  membrane  or  its  follicles ;  at  other 
times  it  contains  globules  of  blood  which  seem  to  signify  a  tendency  to 
the  accomplishment  of  the  natural  hsemorrhage,  or  to  the  recurrence  of 
the  normal  conditions  of  the  function;  frequently  it  is  sero-mucous  as 
if  serum  exuded  from  the  vessels  was  mixed  with  mucus  hyper-secreted 
under  the  influence  of  the  fluxion  of  which  the  follicles  with  all  the 
rest  of  the  uterine  system  are  the  termination.  The  reaction  exercised 
on  the  uterus  by  the  functional  disorder  of  another  organ  may  also 
cause  uterine  leucorrhoea.  The  suppression  of  a  physiological  or 
pathological  function  such  as  lactation,  perspiration,  expectoration, 


LEUCORRHCEA    AND    UTERINE    CATARRH  575 

diarrhoea,  hsemorrhoids,  an  exutory,  &c,,  may  originate  it,  or  the  sup- 
pression of  menstruation  itself.  This  kind  of  leucorrhoea  has  been 
designated  by  the  terms  metastatic  or  supplementari/ ;  but  in  these 
cases  it  is  still  more  difficult  than  in  those  of  amenorrhoea  to  discover 
the  true  pathogeny  of  leucorrhoea  and  to  decide  whether  it  is  really 
supplementary  of  the  fluxion  the  suppression  of  which  coincides  with 
its  appearance,  or  if  it  is,  like  these  fluxes  themselves,  symptomatic  of 
a  common  general  condition  which  causes  both. 

Lastly,  leucorrhoea  often  exists  in  women  who  do  not  menstruate. 
Now,  when  the  menses  are  absent  leucorrhoea  may  be  produced  in  two 
ways  :  like  amenorrhoea  it  may  either  be  symptomatic  of  a  general  state 
which  dominates  both,  or  it  appears  or  is  increased  at  the  time  cor- 
responding with  that  of  the  menses  by  the  fluxion  and  congestion 
which  characterise  this  period :  menstruation  commences ;  its  ter- 
mination by  the  ordinary  crisis  is  impossible ;  it  terminates  by  a 
mucous  discharge  instead  of  a  sanguineous  one.  When  the  first 
monthly  period  has  been  delayed,  when  the  menses  do  not  reappear 
after  an  acute  malady,  or  when  they  begin  to  disappear  in  the  course 
of  chronic  maladies,  e.  g.  in  phthisical  patients,  the  appearance  and 
return  of  menstruation  are  often  announced  for  some  months  by  a 
periodical  leucorrhoeic  discharge,  which  lasts  like  the  menses  for  a  few 
days,  and  which  is  the  indication  of  a  real  uterine  congestion  insufficient 
to  lacerate  the  vessels  and  produce  haemorrhage ;  this  menstrual  leu- 
corrhoea, analogous  to  that  which  accompanies  ovulation  in  some  mam- 
malia, has  been  exceptionally  seen  for  several  years  in  women  who  are 
apparently  in  good  health,  occasionally  even  in  some  who  have  become 
pregnant. 

IV.  Symptomatic  leucorrTicP.a. — Usually  leucorrhoea  is  only  a  symptom. 
The  diseases  which  produce  it  are  of  various  kinds  and  occupy  different 
seats.  These  diseases  may  be  either  acute  or  chronic,  general  or  local, 
diathetic  or  non-diathetic.  Amongst  the  diathetic  causes  we  may 
mention  herpetic,  rheumatic  or  scrofulous  affections ;  amongst  the 
local  causes,  sexual  excitement,  inflammation  of  the  genital  organs  and 
especially  of  their  mucous  membranes,  uterine  catarrh,  or  blennorrhagia, 
which  may  affect  the  vulva,  vagina  and  uterus,  extending  even  to  the 
ovary,  and  which  is  distinguished  by  its  essentially  contagious 
character. 

With  regard  to  the  seat,  leucorrhoea  may  be  limited  to  the  vulva, 
more  frequently  to  the  vagina  or  to  the  uterus.  It  may  invade 
simultaneously  the  mucous  membranes  of  these  three  organs;  it  may 
even  extend  to  the  Fallopian  tubes  and  to  the  ovaries  and  produce 
inflammation  {see  Ovaritis).  It  can  be  distinguished  on  micro- 
scopic examination  by  the  characters  that  I  have  just  assigned  to  the 
various  leucorrhoeic  products  of  the  vulva,  vagina  or  uterus. 

Some  maladies  have  a  greater  tendency  than  others  to  determine  the 
appearance  of  leucorrhoea  simultaneously  or  successively  on  all  the 
mucous  membranes  of  the  genital  economy,  in  place  of  limiting  it  to 
one  of  them.  Eor  instance  herpetic  leucorrhoea  has  a  tendency  to 
invade  alternately,  or  successively,  various  points  of  the  utero-vulval 


576  UTEEINE    DISEASES    IN    DETAIL 

raucous  membrane  and  even  of  the  neighbouring  organs.  Sometimes 
the  uterine  leucorrhrea  diminishes  and  the  vaginal  increases ;  sometimes 
the  latter  is  ameliorated,  and  the  vulva  is  affected;  the  labia,  the  in- 
ternal surface  of  the  thighs  and  the  anus  are  covered  with  eczematous 
or  herpetic  vesicles,  with  pustules  of  impetigo,  or  at  least  they  are 
attacked  by  erythema;  and  then  when  these  organs  begin  to  improve 
the  vaginal  or  uterine  mucous  membrane  is  affected  anew.  I  have 
seen  similar  cases  in  men ;  herpetic  diseases  successively  and  alter- 
nately invading  the  scrotum,  foreskin,  glans,  urethra,  neck  of  the 
bladder,  bladder,  urethra  and  kidney.  The  same  remarks  are  appli- 
cable to  virulent  or  contagious  hlennorrliagic  leucorrliaa,  to  catarrhal 
leucorrlio&a,  to  rheumatic  leucorrhcea  and  to  scrofulous  leucorrhcea. 

A.  Vulval  leucorrhoea. — This  is  common  in  children,  especially  in 
scrofulous  or  herpetic  girls  ;  it  coexists  or  alternates  with  crusts  on  the 
head,  with  impetigo,  eczema,  herpes.  It  is  sometimes  complicated  with 
superficial  ulceration,  engorgement  of  the  inguinal  ganglia,  inflamma- 
tion and  suppuration  of  these  organs.  It  is  evidently  due  to  excessive 
secretion,  to  a  herpetic  eruption,  to  superficial  ulceration  caused  and 
kept  up  by  scrofula,  as  suppurative  maladies  of  other  mucous  mem- 
branes usually  are  at  this  age,  especially  maladies  of  the  mucous 
membrane  of  the  orifices,  the  mucous  membrane  of  the  lips,  the  Schneide- 
rian  membrane,  the  conjunctiva,  the  external  ear,  &c.  It  extends 
rapidly  to  the  vagina ;  I  have  seen  it,  however,  go  further ;  in  making 
a  post-mortem  examination  of  a  child  of  13,  I  remember  having  seen 
the  uterus  and  the  external  half  of  the  Fallopian  tubes  filled  and  dis- 
tended with  epithelial  debris  forming  a  mass  of  cheesy  matter. 

B.  Vaginal  leucorrhcea. — -This  is  rarely  seen  in  children.  It  is  very 
common  in  married  women,  being  caused  by  venereal  excitement,  blennor- 
rhagia,  vaginitis  even,  or  by  pregnancy.  Usually  there  is  neither  swelling 
nor  heat  at  the  vulva,  but  it  may  occur,  the  fluid  in  issuing  may  irritate 
the  mucous  membrane  of  the  labia  and  produce  erythema,  or  at  least 
an  inconvenient  and  sometimes  a  painful  pruritus  is  excited.  The 
discharge  of  the  fluid  is  almost  continuous,  especially  in  pregnant 
women.  When  the  hymen  exists  or  when  the  vulval  ring  has  not  been 
dilated  by  frequent  marital  intercourse,  the  leucorrhoeic  fluid  may  be 
accumulated  for  some  time  in  the  vagina  before  being  discharged, 
and  then  its  issue  may  appear  intermittent.  Frequently  it  is  milky, 
justifying  the  name  of  whites.  Sometimes  it  is  very  liquid,  at  other 
times  rather  consistent,  on  account  of  the  epithelial  elements  which 
it  holds  in  suspension,  but  it  is  never  viscous,  strictly  speaking,  nor 
S'^ey. 

c.  Uterine  leucorrhcea  is  very  rare  in  children,  but  common  m 
chlorotic  girls  and  in  married  women  before  or  after  pregnancy;  in 
many  it  is  abundant  before  and  after  menstruation.  It  may  be  pro- 
voked by  venereal  excesses,  but  usually  is  caused  and  kept  up  by 
uterine  disease,  often  by  catarrh,  sometimes  even  by  inflammation  or 
by  a  rheumatic,  herpetic,  blennorrhagic  or  syphilitic  affection  localised 
on  the  womb,  or  by  the  presence  of  a  polypus,  fibroid  tumour,  simple 
granulations,  an  ulcer,  &c.     Generally  there  is  neither  heat,  nor  pain 


LEUCORRHCEA    AND    UTERINE    CATAKRH 


577 


nor  any  other  symptom  of  disease  of  the  vulva^  vagina  or  neighbouring 
parts.  But  there  is  frequently  a  feeling  of  weight  in  the  pelvis,  lumbar 
and  hypogastric  pains  almost  as  commonly,  with  colics,  especially  in 
young  girls,  corresponding  to  the  contractions  by  which  the  uterus 
expels  the  fluid ;  therefore  the  discharge  is  intermittent  in  place  of 
being  continuous.  Even  when  the  uterine  orifice  is  large  and  the  fluid 
runs  out  witliout  a  uterine  contraction  accompanied  by  pains,  the 
mucus  or  the  muco-pus  is  retained  by  its  viscosity,  and  is  only  detached 
from  the  mucous  membrane  to  which  it  adheres  when  the  mass  is  large 
enough  to  be  dragged  away  by  its  own  weight.  A  flow  of  liquid  then 
escapes  from  the  uterus,  and  finally  from  the  vagina,  from  time  to 
time,  of  which  the  patient  is  conscious  even  when  she  has  not  felt  any 
pain  previously. 

Differential  diagnosis  of  the  various  kinds  of  infantile  leucorrhcea. — 
The  importance  of  this  diagnosis  from  a  medico-legal  point  of  view 
induces  me  to  devote  a  few  lines  to  it.^  The  leucorrhcea  of  children 
may,  as  I  have  already  said,  attack  the  uterus  itself;  but  it  is  more 
common  in  the  vagina,  and  especially  in  the  vulva,  when  the  urethra 
may  be  affected  simultaneously. 

The  chief  symptoms  which  distinguish  infantile  leucorrhcea  caused 
by  an  indecent  assault  (especially  when  blennorrhagic)  from  other  forms 


Fig.  332.— Pavement    epithelium  Fig.  333. — Mucous   corpuscles    with 

in  every  degree  of  development,  some    epithelial    cells    and   oily 

in  epithelial  or  vaginal  leucor-  granulations  in  mucous  or  cervi- 

rhoea.       220   diameters    (Tyler  cal  leucorrhcea.     220  diameters. 
Smith). 

of  leucorrhcea  are  the  following :  traces  of  contusion,  swelling,  ecchy- 
mosis,  turgescence  of  the  vessels  of  the  vulva  and  vagina,  the  rapid 
and  intense  development  of  the  malady,  purulent  discharge  of  a  green- 
yellow  hue,  and  abundant  enough  to  cover  the  external  parts  and  soil 
the  linen  in  many  places,  thick  enough  to  glue  the  vulval  lips  together 

'  See  Tardieu,  Etude  .'.ur  les  attentats  am:  moeurs,  4,^  edit.  Paris,   1862, 
p.  20  and  following. 

37 


578  UTERINE    DISEASES    IN    DETAIL 

when  dry,  simultaneous  discharge  from  the  vagina  and  urethra.  This 
last  sign  is  important,  as  being  peculiar  to  virulent  and  contagious 
leucorrhosa;  for  according  to  Tardieu,  the  violence  exercised  on  the 
genital  organs  of  a  child  by  the  healthiest  man  may  produce  as  acute 
and  as  violent  an  inflammation,  as  well  as  a  discharge  as  abundant  and 
thick  as  that  caused  by  the  approach  of  a  man  affected  with  blennor- 
rhagia  or  any  other  contagious  disease. 

V.  Uterine  catarrh  is  the  malady  which  most  frequently  produces 
uterine  leucorrhoea.  It  is  sometimes  confounded  with  inflammation  of 
the  uterine  mucous  membrane,  and  described  as  internal  metritis, 
mucous  metritis^  endometritis.  It  sometimes  assumes  the  acute  form, 
frequently  the  chronic;  it  may  be  complicated  with  inflammation, 
erosion,  ulceration  of  the  mucous  membrane,  as  occurs  in  old  bronchial 
or  intestinal  catarrhs.  It  must  not,  however,  be  confounded  with  these 
various  morbid  states,  or  regarded  as  being  only  symptomatic  of  them, 
for  it  has  distinctive  characters  which  allow  a  differential  diagnosis  to 
be  established.  What  characterises  it  is  the  peculiarity  of  its  manifes- 
tation, the  causes  which  produce  it,  its  mode  of  development,  the 
analogy  of  the  complications,  the  speciality  of  the  treatment.  The 
speciality  of  its  manifestation  is  the  discharge  itself.  How  often  the 
uterine  mucous  membrane  is  inflamed,  red,  painful,  even  suppurating 
like  that  of  the  vagina  without  producing  any  discharge  !  How  often, 
on  the  contrary,  this  discharge  exists  alone,  abundant,  seldom  purulent, 
but  often  muco-purulent  or  merely  mucous,  the  glandular  hyper- 
secretion increased,  fatiguing  patients  by  its  quantity  and  persistence, 
ending  by  producing  swelling  of  the  mucous  membrane  and  pain  in  the 
organ  by  hypertrophy  of  the  follicles,  but  not  accompanied  by  really 
inflammatory  symptoms  except  in  the  acute  state  caused  by  a  sudden 
attack  or  after  a  long  duration  from  the  effect  of  organic  alterations 
produced  by  prolonged  functional  alteration  !  The  external  causes 
producing  it  are  the  same  as  those  which  usually  determine  localised 
catarrhal  affections  on  other  mucous  membranes :  coryza,  bronchial 
catarrh,  intestinal  catarrh,  &c.  I  have  often  seen  leucorrhoea  follow  a 
sudden  chill  of  the  genital  organs  and  abdomen  occurring  in  women 
while  perspiring,  either  from  sitting  down  on  the  cold  grass  or  on  a 
damp  stone,  or  from  taking  inopportunely  a  cold  sitz-bath  followed  by 
no  reaction,  or  from  having  the  genitals  exposed  to  a  current  of  cold 
air.  I  have  seen  men  contract  vesical  and  prostatic  catarrh  from  the 
same  causes.  The  influence  of  these  causes  is  still  more  marked  when 
a  number  of  women  are  affected  as  by  an  epidemic.  TrousseU  says 
that  when  the  Font  des  Arts  was  finished  at  Paris  it  became  a  fashion- 
able promenade.  Ladies  sat  there  after  sunset  as  in  the  public  gardens, 
and  owing  to  the  cool,  damp  air  from  the  river  were  attacked  with 
leucorrhoea.  We  find  proofs  of  the  epidemic  character  of  uterine 
catarrh  in  Blatin's  work,  and  in  the  article  Leucorrhee  in  the  Biction- 
naire  des  Sciences  medicales,  in  which  are  recorded  the  facts  observed 
by  the  Breslau  physicians  in  1702,  by  Morgagni  in  Italy  in  1710,  by 

'  Des  ecoiolemeiits  particuliers  amcfemmes.   Paris,  1842. 


LEDOORRHGEA    AND    UTERINE    CATAREH  579 

Bassius  of  Magdebourg  at  Halle  in  1730,  by  Raulin'  at  Paris  in  1765, 
by  Leake  in  England,  concurrently  with  catarrh  and  diarrhoea ;  the 
observations  made  at  Berlin  in  1713  are  also  given,  and  those  in 
Prance  by  Eoux  in  1769.  Its  mode  of  development  presents  this 
peculiarity,  that  it  often  depends  on  a  feeble  constitution,  on  a 
lymphatic  temperament,  a  susceptibility  of  the  mucous  membranes, 
and  an  impressionability  to  the  action  of  damp  cold  and  to  sudden 
varieties  of  temperature,  or  to  the  hygrometric  state  of  the  air,  being 
determined  by  the  action  of  the  external  causes  just  mentioned — that 
is,  by  circumstances  which  beget  the  catarrhal  affection  and  which 
produce  localisation  on  the  nasal,  bronchial,  vesical,  intestinal  mucous 
membranes. 

Acute  uterine  catarrh  may  be  complicated  by  a  certain  degree  of 
inflammation.  The  mucous  membrane  affected  by  the  morbid  cause  is 
first  painful  and  the  secretion  is  diminished.  In  proportion  as  reaction 
takes  place  hypersecretion  commences,  being  more  or  less  intense  and 
more  or  less  altered.  Hypogastric  pain  is  accompanied  by  heat,  pelvic 
discomfort,  pain  during  defecation  and  micturition,  assuming  occasion- 
ally the  character  of  colics. 

Chronic  uterine  catarrh  follows,  or  this  form  may  be  assumed  from 
the  commencement  j  sometimes  also  it  follows  metritis,  which  develops 
in  the  uterine  glands  a  tendency  to  hypersecretion  which  is  favoured 
or  prepared  by  a  general  tendency. 

Subjective  signs. — Hypersecretion,  this  discharge  being  apparently 
more  weakening  than  that  from  the  vagina,  and  sometimes,  when  it  is 
abundant,  coinciding  with  an  irritation  which  extends  from  the 
uterine  mucous  membrane  to  that  of  the  vagina,  vulva,  the  internal 
surface  of  the  thighs,  where  it  produces  irritation,  a  kind  of  erythema, 
and  even  slight  epithelial  desquamation.  Menstrual  disorders,  usually 
dysmenorrhoea,  occasionally  metrorrhagia ;  in  the  latter  case,  it  is 
seldom  that  there  is  not  some  alteration  of  the  mucous  membrane 
symptomatic  of  a  concomitant  morbid  state  such  as  ulceration,  granu- 
lations, fungosities.  Pains  beginning  at  the  sacrum  and  terminating 
in  the  groins  and  pubis,  accompanied  by  colics  preceding  the  expul- 
sion of  the  muco-pus  accumulated  in  the  uterine  cavity,  and  compli- 
cated with  a  feeling  of  discomfort,  weight  and  pelvic  fulness.  Very 
often  an  impression  on  some  other  part  of  the  body,  such  as  the 
sudden  sensation  produced  by  laying  the  hand  on  marble,  reacts  on  the 
uterus  awakening  a  slumbering  pain  and  determining  hypersecretion 
with  expulsion  of  mucus.  Gastralgia  is  soon  added  to  these  pains,  a 
sensation  of  weariness  and  dragging  extending  from  the  epigastrium 
to  the  dorsal  region  between  the  shoulders,  resulting  from  derange- 
ment of  the  digestive  functions,  from  the  general  debiHty  which 
follows,  from  the  chlorosis  and  chloro-ansetnia  which  are  its  conse- 
quences. Dyspeptic  symptoms  are  developed :  heartburn,  acidity, 
vomiting,  abdominal  distension  are  often  followed  by  constipation  or 
catarrh  in  the  lower  portion  of  the  intestine,  painful  defecation, 
tenesmus,  mucus  passed  with  the  feeces ;  the  urine  becomes  muddy, 

'  Tralte  desjiueurs  blanches  avec  la  methode  de  les  gucrir.  Paris,  17G6. 


580  UTERINE    DISEASES    IN    DETAIL 

loaded,    muco-purulent,   and    micturition    is   painful.      Emaciation, 
languor,  sadness  complete  the  picture. 

Objective  signs. — Tension  and  resistance  in  the  hypogastrium,  sensi- 
bility of  the  cervix ;  digital  touch  discovers  a  characteristic  glairy  or 
purulent  mucus  ;  there  is  often  flaccidity  of  the  uterine  walls,  some- 
times increased  size  of  the  neck  or  body  ;  the  latter  becomes  globular, 
especially  when  by  occlusion  of  the  orifices  from  the  swelling  of  the 
mucous  membrane  or  by  their  obliteration  from  the  formation  of 
bands  or  the  adhesion  of  ulcerated  surfaces,  the  products  of  secretion 
are  accumulated  and  retained  in  the  uterine  cavity.  The  hollow 
uterine  sound  penetrates  with  some  difficulty  ;  but  when  once  it  has 
done  so,  it  is  mobile  in  every  direction,  showing  an  increased  capacity 
of  the  cavity  of  the  womb ;  sometimes  mucus  is  discharged  from  its 
canal.  Frequent  exuberations  are  observed  on  the  cervix,  even  on  the 
border  of  the  orifice  and  particularly  on  the  inferior  lip,  a  pheno- 
menon which  may  depend  on  maceration  of  the  epithelium  by  the 
raucous  secretion  as  Gosselin  has  remarked,^  but  which  may  also 
exist  as  a  complication,  as  in  more  serious  alterations  such  as 
granulations,  fungosities,  and  follicular  cysts.  I  agree  with  Scan- 
zoni^  that  persistent  leucorrhosa,  like  uterine  congestion  which 
often  accompanies  it,  may,  by  the  irritation  and  hypersemia  which 
it  keeps  up  in  the  organ,  favour  the  development  of  chronic  me- 
tritis, ulcerations,  granulations,  uterine  fungosities,  follicular  cysts, 
fibroid  bodies,  &c.  Catarrhal  leucorrhoea  is  rarer  in  the  vagina 
than  in  the  uterus  ;  but  may  manifest  itself  in  the  former  organ, 
succeeding  vaginitis ;  it  may,  especially  in  the  acute  form,  exist 
simultaneously  in  both.  It  is  the  same  with  rheumatic  leucorrhoea 
which  scarcely  differs  from  catarrhal  leucorrhoea :  but  usually  rheu- 
matism affects  the  muscular  tissue  rather  than  the  mucous  membrane 
of  the  uterus. 

VI .  Hydrorrhcea.  Hydrometria.  Physometria? — This  is  the  occa- 
sion to  say  a  few  words  on  these  rare  morbid  states,  the  existence  of 
v\'hich  has  often  been  doubted.  Hydrorrhoea  is  the  abundant  discharge 
of  an  aqueous  fluid  from  the  uterine  os;  hydrometria,  the  tumour 
formed  by  the  retention  of  this  fluid  in  the  uterus ;  physometria,  the 
distension  of  the  uterus  by  gases. 

Apart  from  amniotic  dropsy,  the  results  of  abnormal  pregnancy, 

1  De  la  valeur  symptomatique  des  ulcerations  du  col  uterin  {Archiv.  gener. 
de  med.,  4^  serie,  t,  ii,  p.  129,  1815). 

2  Op.  cit.,  p.  175. 

3  Lafosse,  Theses  de  Strasbourg,  1816,  No.  39. — Tessier  of  Lyons,  De  I'Hy- 
dropisie  et  de  la  Tympanite  uterines  Tiors  de  I' Stat  de  gestation  {Gaz.  med.  de 
Paris,  p.  8,  1844). — Jobert,  De  I'Hydropisie  du  col  uterin  {Journ.  de  Chir., 
t.  i,  p.  265.  Paris,  1843). — P.  Franck,  Traite  de  med.  prat.,  t.  ii,  p.  20.  Paris, 
1842. — Bonet,  Sepulcliretwm,  L.  iii,  sect,  xxi,  obs.  55. 

Consult  also  for  Hydrometria:  Dard,  Gazette  medicale  de  Paris,  1855,  p. 
44  ;  Shanks,  Id.,  1855,  p.  178  ;  and  a  case  in  the  Gazette  hehdomadaire,  1855, 
p.  411 ;  Malicheis,  Gazette  des  Hopitaux,  1866,  p.  323. 

For  Physometria :  Roy  {Gazette  inedicale  de  Paris,  1833,  p.  629)  ;  Batten 
(Id.,  1834,  p.  505)  ;  PoUet  (Id.,  1850,  p.  114) ;  and  Canstatt's  Jahreshericht, 
1849,  p.  333. 


LEUCORRHCEA   AND    UTERINE    CATARRH  581 

moles,  alterations  in  the  dead  body  of  a  foetus,  its  membranes,  or  the 
placenta,  the  intra-uterine  opening  of  a  tubal  or  ovarian  cyst,  and  the 
other  causes  of  false  leucorrhsea  already  enumerated,  hydrorrhcea  and 
hydrometria  can  only  occur  from  hypersecretion  of  the  uterine  mucous 
membrane.^  The  fluid  secreted  may  be  altered  in  its  quantity  and 
quality,  be  discharged  continuously  or  intermittently,  be  completely 
retained  in  the  uterine  cavity  and  even  produce  gases ;  these  are  the 
only  direct  causes  to  which  hydrorrhoea,  hydrometria  and  physometria 
can  be  attributed.  The  serous,  sero-sanguinolent,  sanious,  ichorous 
discharges  produced  by  the  serious  organic  alterations  of  the  mucous 
membrane,  are  sometimes  considerable,  but  they  hardly  exceed  the 
limits  of  the  symptomatic  discharges  included  under  the  name  of  false 
leucorrhoea.  Idiopathic  hydrometria  only  originates  from  the  secretion 
of  the  uterus. 

Hydrorrhoea  therefore  supposes  an  increase  of  the  uterine  secretion, 
accompanied  usually  by  a  diminution  in  the  density  of  the  secreted 
fluid.  This  diminution  in  density,  which  is  common  to  dropsies  of 
other  organs,  is  caused  by  the  precipitation  of  the  solid  elements  or  by 
an  alteration  in  the  secretion  of  the  organ  which  is  brought  about  by 
the  distension  and  attenuation  of  the  latter  to  the  condition  of  a  kind 
of  fibro-serous  capsule.^  Hydrometria  supposes  the  imperforation  of 
the  neck,  more  frequently  its  obliteration  or  its  obstruction  by  the 
presence  of  a  polypus,  by  a  well-marked  flexion  or  an  abnormal  tume- 
faction of  the  columns  of  the  isthmus  which,  fitting  closely  into  each 
other,  close  the  os  internum,  or  even  by  an  interstitial  uterine  tumour 
or  an  extra-uterine  one  such  as  an  ovarian  cyst,^  in  short,  by  the  same 
causes  to  which  we  have  already  attributed  (p.  270)  retention  of  the 
menses  (hematometria).  It  is  evident  that  these  two  conditions  (abun- 
dant secretion  and  retention  of  the  fluid  secreted)  are  alone  favorable 
to  the  formation  of  a  fluid  collection  in  the  uterus  and  to  the  consecu- 
tive distension  of  the  walls  of  this  organ.  It  is  also  evident  that  it  is 
after  the  menopause  or  prolonged  amenorrhoea  that  hydrometria  must 
be  produced  ;  for  in  other  conditions  there  would  be  retention  of  blood 
instead  of  mucus. 

1.  Hydrometria  \ki.vcs>  defined  is  the  uterine  ascites  or  uterine  dropsy 
of  the  ancients. — The  diagnosis  may  present  some  difficulty,  especially 
when  the  uterus  is  very  thin  and  much  distended ;  the  question  is  then 
of  a  differential  diagnosis  between  hydrometria,  hematometria,  and  preg- 
nancy (p.  281).  In  every  case  there  is  amenorrhoea  or  at  least  reten- 
tion of  the  menses.  In  most  cases  the  size  of  the  uterus  does  not 
exceed  that  of  the  same  organ  in  the  sixth  month  of  gestation,  and  it 
only  reaches  these  dimensions  slowly.  Exceptionally  the  fluid  may 
pass  into  the  Fallopian  tubes,  distend  them  gradually  and  find  an  issue 
into  the  peritoneal  cavity,  or  it  may  distend  the  uterus  to  the  ])oint  of 
causing  rupture. 

'  The  existence  of  idiopathic  liydrometria  has  been  proved  by  autopsies  made 
by  Cruveilliier  {Anat. i)atholo(j.,i.  ii,  p.  Sl'J)  and  by  Tliompson  {Medic. -chir. 
Transactions,  xiii,  part  i,  p.  170). 

"  Scauzoni,  op.  cit.,  p.  I'Jfi. 


582  UTERINE    DISEASES    IN    DETAIL 

Pancture  of  the  uterus  through  the  hypogastriuni^  may  be  necessi- 
tated, or  better  still  puncture  of  the  cervix  from  the  vagina^^  dilatation 
of  the  cervico-uterine  canal,  suppression  of  the  obstacle  preventing  the 
discharge  of  the  accumulated  fluid,  all  these  methods  being  followed 
up  with  great  care  to  keep  the  uterus  open  by  means  of  a  sound  or 
tents,  to  make  detersive  and  afterwards  caustic  injections,  to  exercise 
methodic  compression  on  the  hypogastrium,  to  provoke  contractions  of 
the  muscular  fibres  of  the  uterus  and  the  gradual  return  of  this  organ 
to  its  normal  dimensions.^  Cases  have  been  described  in  which  the 
fluid  was  discharged  from  the  uterus  by  perforation  due  to  ulceration : 
this  evacuation  may  be  very  dangerous.^ 

"When  the  isthmus,  in  place  of  being  obliterated,  is  only  obstructed 
by  a  temporary  tumefaction,  this  mechanical  obstacle  may  temporarily 
hinder  the  exit  of  a  single  drop  of  mucus  from  the  uterine  cavity,  as 
the  swelling  of  the  median  or  one  of  the  lateral  lobes  of  the  prostate 
prevents  the  discharge  of  a  single  drop  of  urine  from  the  bladder.  If 
this  obstacle  yields  to  the  variations  which  menstruation,  various 
movements  and  muscular  contractions  produce  in  the  position  or  in 
the  form  of  the  uterus,  there  may  be  alternative  retention  and  evacua- 
tion of  serous  or  viscous  fluids,  sometimes  in  great  quantity.  I  have 
seen  five  cases  of  this  disease.^ 

2.  Fhysometria,  pneumatosis  or  uterine  tympanitis  when  not  merely 
the  result  of  the  introduction  of  air  by  the  injection  syringe,  or  when 
not  dependent  on  the  formation  of  gas  produced  by  the  decomposition 
of  the  foetus  or  placenta,  a  polypus,  or  a  menstrual  clot,  may  be  due 
to  the  alteration  of  the  sero-mucous  fluid  of  hydrometria,  but  this  is 
rare.  It  is  evident  that  the  gas  always  occupies  the  upper  part  of  the 
uterus^  in  the  region  of  the  navel  or  hypogastrium^  according  to 
whether  the  patient  is  standing  or  lying.  Percussion  and  succussion 
usually  enable  us  to  perceive  the  peculiar  sensation  as  well  as  to  hear 
the  sound  characteristic  of  air  mixed  with  fluid  in  the  uterine  cavity. 
Lastly,  the  discharge  of  this  gas  may  take  place  simultaneously  with 
the  fluid  in  a  noisy  manner.^  The  treatment  is  the  same  as  tliat  of 
hydrometria. 

Treatment. — Leucorrhoea,  especially  when  acute,  may,  like  every 
catarrh,  be  cured  spontaneously.  Treatment  ought  not,  however, 
to  be  neglected  on  that  account,  for  it  has  often  a  great  tendency 
to  pass  into  the  chronic  form,  and  chronic  leucorrhcea  is  one  of  the 

*  Wirer  has  extracted  in  this  way  32  lbs.  of  a  thick  fluid  from  the  uterus  of 
a  woman  of  53  years  of  age,  who  recovered  {Ann.  litt.  med.  etr.,  ii,  290). 

^  Cruveilhier  has  mentioned  a  case  in  which  this  puncture  was  followed  by 
death  {Anat.  path.,  i,  281). — See  also  Clements  of  Frankfort  {Gazette  medicale 
de  Str'asboiorg,  1813,  p.  371). 

^  Fantonelli,  Hydrometrie  guerie  par  le  seigle  ergote  {Gazette  medicale  de 
Paris,  1837,  p.  234). 

*  Luigi  {Annali  universali  di  rtiedicina.  Milano,  March,  1861). 

•''  Browne  has  described  a  case,  quoted  by  Duges  and  Boivin  (Op.  cit.,  t.  i, 
p.  259). 

®  Gooch  has  seen  a  case  of  this  kind  {Diseases  of  Women,  p.  241) ;  and 
Scanzoni  two  (op.  cit.,  p.  198). 


LEUOOERHCEA    AND    UTERINE    CATARRH  583 

most  obstinate  diseases.  It  gradually  produces  disorders  of  the  diges- 
tion, impoverishment  of  blood,  emaciation  and  consumption  mani- 
fested by  languor,  paleness  of  the  face,  alterations  of  the  features  and 
complexion,  the  whole  being  designated  by  the  term  fades  uterina. 
The  physician  ought  therefore  to  explain  to  the  patient  the  necessity 
for  prolonged  treatment,  not  only  on  account  of  the  difficulty  of 
obtaining  cure  but  of  the  frequent  relapses. 

Vulval  leucorrhcea  in  children  requires  more  immediate  attention 
still;  it  ought  to  be  cured  at  once  to  prevent  the  little  patients  from 
acquiring  the  habit  of  touching  the  genital  organs  with  their  hands, 
which  keeps  up  and  increases  the  evil  and  sometimes  leads  to  mastur- 
bation. On  the  other  hand,  leucorrhcea  in  phthisical  patients  should 
not  be  treated  except  in  the  way  of  paying  great  attention  to  cleanli- 
ness which  alleviates  the  pain  and  irritation.  It  plays  the  part  of  an 
anal  fistula  or  artificial  exutory,  and  its  suppression  sometimes  aggra- 
vates the  pulmonary  symptoms  and  hastens  death.  Most  practitioners 
are  agreed  as  to  this.  Lagneau  was  strongly  of  this  opinion,  and 
Lisfranc  also  [Cliniqiie  cJdrurgicale,  t.  ii,  p.  300),  who  says,  "  I  have 
observed  a  great  number  of  women  in  whom  leucorrhoea  diminished  or 
suspended  the  progress  of  pulmonary  phthisis,  sometimes  even  check- 
ing it ;  hence  the  necessity  for  respecting  leucorrhoea  when  there  is  a 
morbid  visceral  affection.^^ 

A.  Treatment  of  acute  leucorrhcea  ouglit  almost  always  to  be  general 
as  well  as  local. 

1.    General  treatment  is  much  more  important  than  one  would  be 
inclined  to  think :  it  is  almost  impossible  to  cure  leucorrhoea  without 
resorting  to  it,  and  in  some  cases  it  alone  is  sufficient.     It  is  so  in 
chlorotic  patients  when  the   leucorrhcea  is   dependent  on   functional 
disorder.    In  such  cases  injections,  local  applications  and  cauterisation 
may  be  dispensed  with.     What  is  required  are  sedatives,  antispasmo- 
dics, tonics,  iron,  mineral  waters  and  hydropathy.     General  treatment 
is  usually  sufficient  in  acute  catarrhal  leucorrhoea.     We  should  remove 
the  causes,  subdue  the  complications,  especially  inflammation  when  it 
exists,  by  rest  and  emollients  if  not  by  antiphlogistics,  e.  g.  by  general 
baths,  sitz-baths,  tepid  and  sedative  irrigations,  enemata ;  avoiding  chills, 
especially   sudden   changes   of  temperature,    by  wearing  flannel  and 
making  dry  frictions  over  the  whole  surface  of  the  skin ;  and  keeping  up 
the  strength  by  tonic  but  unstimulating  diet.     These  means,  however, 
are  not  always  enough :  sometimes  we  should  try  to  bring  on  a  crisis 
as  in  the  treatment  of  bronchial  catarrh.     The  skin  from  its  great 
extent  and  the  influence  which  it  may  have  had  in  the  development  of 
the  catarrh  from  exposure  to  a  chill,  appears  the  most  favorable  organ 
for  the  establishment  of  this  crisis.    With  this  aim  in  view  diaphoretics 
are  employed  to  promote  perspiration.    When  leucorrhoea  persists  and 
threatens  to   pass  into   the  chronic  form,  this   diaphoretic  action  is 
transformed  into  revulsion  by  sioeating,  or  irritating  or  serous  revul- 
sion by  the  use  of  dry  or  stimulating  frictions  over  the  whole  surface 
of  the  body,  rubefacients,  epispastics,  blisters,  or  at  least  frictions  with 
croton  oil,  so  as  to  obtain  a  mihary  eruption  which  is  covered  by  au 


584  UTERINE    DISEASES    IN    DETAIL 

adhesive  paper  to  spare  the  patient  too  great  pain.  If  cutaneous 
revulsion  is  insufficient^  intestinal  revulsion  may  be  added  by  repeated 
purgatives.  The  cure  which  is  quickly  obtained  in  this  way  should 
be  kept  up  by  overcoming  the  debility  which  predisposes  to  relapses 
and  chronicity  by  administering  iron,  cold  baths  followed  by  frictions, 
residence  in  the  country,  &c. 

2.  Local  treatment. — Lastly,  passage  to  the  chronic  state  should  be 
prevented  by  the  use  of  local  astringents :  tepid  vaginal  injections 
(tannin,  coal  tar,  sulphate  of  zinc  or  copper,  alum) ;  inert  or  astringent 
powders  like  subnitrate  of  bismuth,  alum  alone  or  mixed  with 
starch,  applied  to  the  vagina  by  insufflation  or  on  a  tampon;  and  by 
painting  the  vagina  with  a  weak  solution  of  nitrate  of  silver  or 
tincture  of  iodine.  These  means,  however,  though  heroic  in  chronic 
leucorrhoea,  should  be  cautiously  employed  in  the  acute  form. 

B.  Treatment  of  chronic  leucorrhoea. — 1.  Prom  the  beginning  it 
often  affects  this  diathetic  character,  which  shows  the  necessity  of 
attacking  it  by  general  treatment.  It  does  not  necessarily  follow  that 
it  has  been  originated  by  a  diathesis :  defective  and  disordered  men- 
struation, pregnancy,  abortion,  delivery,  physiological  excitement, 
excesses,  mechanical  irritation,  the  sudden  invasion  of  an  acute  catar- 
rhal affection  have  often  been  its  starting-point ;  but  a  diathesis,  the 
latent  existence  of  which  had  passed  unobserved  till  then,  finding  in 
this  morbid  state  an  opportunity  to  become  localised,  is  not  long  in 
replacing  the  occasional  cause  the  action  of  which  is  soon  exhausted ; 
it  imprints  its  character  on  the  leucorrhcea  and  soon  becomes  with  the 
alteration  of  tissue  which  is  dependent  on  the  duration  of  the  disorder, 
the  principal  if  not  the  only  cause  of  its  persistence.  Whatever  point 
may  have  been  invaded  by  a  pathological  action,  however  limited  the 
space  on  which  its  evolution  is  effected,  however  slight  the  symptoms 
of  its  presence  may  be,  a  pre-existing  affection  almost  always  takes  this 
opportunity  of  ceasing  to  be  latent ;  it  manifests  itself  externally,  and 
forms,  if  not  the  very  nature  of  the  morbid  state,  at  least  one  of  its 
most  serious  complications.  Therefore  even  when  not  diathetic  origin- 
ally, leucorrhoea  soon  becomes  so.  What  takes  place  in  women  in  the 
case  of  leucorrhoea  is  similar  to  what  occurs  in  men  in  the  case  of 
chronic  discharges  from  the  urethra  and  prostate.  Nothing  is  more 
easily  or  quickly  cured  in  a  healthy  man  of  good  constitution  :  nothing 
more  difficult  in  a  catarrhal,  rheumatic,  gouty,  herpetic  or  scrofulous 
subject,  I  have  seen  so  many  examples  in  both  sexes  of  the  difficulty 
of  effecting  a  cure  in  such  circumstances,  and  of  the  necessity  of 
resorting  to  antidiathetics  and  restoratives,  of  the  insufficiency  of  local 
treatment  employed  alone,  of  the  success  of  the  same  treatment  when 
preceded  by  general  treatment,  that  I  have  no  hesitation  in  saying 
that  this  is  the  true  secret  of  the  treatment  and  cure  of  these  maladies. 
The  affections  which  exercise  most  influence  on  the  duration  of  leucor- 
rhoea may  be  arranged  as  to  their  frequency  almost  in  the  following 
order :  chlorosis,  chloro-ansemia,  catarrh  and  rheumatism,  herpetic, 
scrofulous  or  syphilitic  diathesis.  Each  of  these  is  the  source  of  a 
special  indication,  sometimes  specific;  in  this  way  iron,  alteratives. 


LEUCORRHCEA    AND    UTERINE    CATAEEH  585 

iodine,  mercury,  arsenic,  iodide  of  iron  and  cod-liver  oil  may  be  admi- 
nistered successfully  in  the  treatment  of  leucorrhoea  in  children, 
according  to  the  nature  of  the  affection  which  keeps  up  this  morbid 
condition.  At  the  head  of  these  means  we  must  place  restoratives, 
tonics,  quinine,  iron,  residence  in  the  country,  change  in  the  mode  of 
of  life,  and  especially  climate.  I  have  seen  striking  examples  of  the 
influence  of  the  change  to  a  dry  and  warm  climate  from  a  cold  and 
damp  one. 

The  balsams,  tar  water,  pills  of  turpentine,  in  leucorrhoea  as  in  all 
other  catarrhal  diseases,  act  simultaneously  on  the  base  or  affection  and 
on  the  form  or  hypersecretion.  I  find  tar  water  of  great  use  and  it  is 
not  repugnant  to  patients  when  mixed  with  seltzer  water.  Ergot  has  a 
more  direct  action  on  the  uterus  and  has  been  employed  with  success. 
Marshall  Hall,^  Bazzoni,-  recommend  it  in  chronic  leucorrhoea,  one 
drachm  boiled  in  eight  ounces  of  water,  half  to  be  taken  one  day,  the 
other  half  the  next;  they  say  that  very  rarely  more  is  required.  It 
may  also  be  taken  in  powder  every  six  hours  in  varying  doses.  It  is 
evident  that  it  may  render  great  service  in  cases  where  the  cavity  of 
the  uterus  is  the  seat  of  the  excretion,  by  stimulating  the  weakened 
contractility  of  the  walls  of  the  organ.  Mineral  waters  are  often 
recommended  but  are  not  always  efficacious.  Natural  or  artificial 
iron  baths,  so  highly  thought  of  by  some  physicians,  are  useful  in 
cases  of  chlorotic  leucorrhoea  ;  but  if  another  diathesis  is  added  to  the 
chlorotic  they  may  be  more  hurtful  than  useful.  I  have  even  seen 
some  chlorotic  patients  to  whom  they  have  done  no  good,  whilst 
alkaline  waters,  but  especially  sulphur  and  sea  bathing,  have  been  very 
beneficial.  In  doubtful  cases  therefore  we  should  try  different  means 
in  place  of  obstinately  persevering  with  one  which,  however  valuable, 
has  its  limits.  Sulphur  baths  and  sea  bathing  are  efficacious  in 
scrofulous  children.  Hydropathy,  however,  is  much  more  generally 
useful.  In  chronic  uterine  catarrh  cold  water  employed  in  various 
ways  with  the  graduated  and  energetic  reactions  provoked  by  its 
methodic  application  produces  wonderful  results.  It  is  the  best 
revulsive  and  the  best  tonic  and  cannot  be  too  much  used  in  the 
treatment  of  this  disease.  When  necessary,  the  douche  may  be  pre- 
ceded by  a  vapour  bath  which  determines  revulsion  on  a  large  surface 
and  by  abundant  sweating  helps  to  restore  the  functions  of  the  skin, 
substituting  cutaneous  perspiration  for  the  morbid  flux  of  leucorrhoja. 
Only  w^e  must  beware  of  weakening  patients,  and  take  care  to  follow 
up  this  medication  by  tonic  treatment. 

When  vapour  baths,  dry  frictions  and  hydropathy  are  contra-indi- 
cated, we  may  resort  to  the  revulsion  produced  on  the  digestive  tube 
by  purgatives,  or  on  the  skin  by  epispastics.  I  cannot,  however, 
recoii)niei\d  this  kind  of  revulsion  :  patients  affected  with  chronic 
leucorrha3a  being  generally  weak  and  dyspeptic,  the  only  result  is 
increased  debility  and  irritation.    Cutaneous  epispastics  also  sometimes 

^  London  Medic,  and  Phys.  Journal,  vol.  Ixi,  p.  399,  1829. 
-  Oinodei,  Annali  di  medicina.  May,  1831. — Lazowski,  Revue  therapeiitique 
dn  MidiA.  v,  p.  211,  1853. 


586  UTERINE    DISEASES    IN    DETAIL 

irritate  greatly  by  the  pain  whicti  they  cause  and  the  rest  they  neces- 
sitate, especially  when  applied  to  the  abdomen.  Therefore  I  seldom 
use  purgatives  and  then  only  at  the  end  of  acute  leucorrhoea  to 
prevent  its  passage  to  the  chronic  form,  or  during  the  treatment  of 
the  latter  as  laxatives  to  keep  the  bowels  regular,  increase  the  appetite 
and  stimulate  digestion,  rather  than  as  a  revulsive  on  an  organ  which 
ought  to  be  spared.  Schcenbein  and  Aran^  have  recommended 
enemata  containing  aloes  suspended  in  a  kind  of  mucilage  of  soap  and 
water.  The  results  are  successful  in  proportion  to  the  time  they  are 
retained.  One  may  be  taken  every  night  or  every  two  nights  till 
there  is  irritation  of  the  rectum  or  anus ;  they  should  then  be  sus- 
pended for  a  few  days  and  resumed  if  found  useful.  They  are  only 
suitable  when  all  the  congestive  or  inflammatory  symptoms  have  dis- 
appeared :  after  all,  they  are  very  uncertain,  and  the  same  may  be 
said  of  enemata  of  colocynth.  The  application  of  blisters  to  the 
cervix  is  very  useful  in  cases  of  uterine  leucorrhcea  especially  when 
it  is  the  body  of  the  uterus  that  is  affected,  when  there  is  no 
discharge  from  the  vulva  and  vagina  and  when  the  cervix  is  almost 
healthy,  merely  engorged  or  at  least  when  it  is  not  the  principal  seat 
of  the  discharge.  The  blister  is  applied  according  to  the  rules  pre- 
viously laid  down. 

One  blister  is  not  enough,  it  is  almost  always  necessary  to  apply  a 
second,  third,  and  sometimes  even  a  fourth  at  intervals  of  a  fort- 
night, taking  care  to  prevent  iDf3ammation  by  rest,  the  use  of 
baths  and  emollients,  continuing  general  treatment  as  much  as 
possible.  It  is  needless  to  say  that  blisters  should  not  be  applied 
at  the  monthly  period.  I  have  found  them  very  useful  when  circum- 
stances prevented  the  use  of  hydropathy  and  mineral  waters.  Simul- 
taneously, I  recommend  the  abdomen  to  be  wrapped  in  cotton  wool 
with  an  india-rubber  bandage  over  it  so  as  to  keep  up  constant  moist 
heat. 

2.  We  have  now  come  to  the  local  treatment  of  chronic  leucor- 
rhcea. This  should  frequently  be  associated  with  general  treat- 
ment; but  with  the  exception  of  simple  irrigations  or  emollient  and 
detersive  injections  to  promote  cleanliness  and  alleviate  pain,  topical 
applications  should  generally  be  confined  to  the  last  stage,  when  the 
constitution  is  sufficiently  modified  to  give  us  reason  to  hope  that 
energetic  local  action  may  put  a  stop  to  the  discharge. 

For  vulval  and  vaginal  leucorrhcea  these  local  applications  are : 
injections,  powders  and  various  applications.  Their  object  is  to 
modify  directly  the  surface  of  the  mucous  membrane  and  the  cavity 
of  the  follicles  which  are  the  seat  of  leucorrhoeal  discharge,  in  fact 
the  local  morbid  state,  which  seems  to  keep  up  the  discharge  as  if  by 
habit  of  hypersecretion. 

The  injections  or  rather  vaginal  irrigations  made  on  the  bidet  with 

'  Bulletin  de  therapeutique,  t.  liv,  p.  193.  Maladies  de  I'uterus,  p.  464.  The 
prescription  is  :  Aloes  gr.  Ixxv  ;  Saponis  gr.  Ixxv  ;  Aq.  ferventis  3iij  ;  to  be 
injected  at  bedtime  when  cold,  after  having  emptied  the  intestine  by  a  tepid 
enema. 


LEUCOERHCEA   AND    UTEEINE    CATAERH  587 

the  hydroclyse  should  usually  be  tonic,  astringent  and  caustic.  They 
are  sometimes  made  with  the  mineral  water  itself  during  the  bath, 
whether  emollient,  alkaline,  iron  or  sulphur.  After  having  injected 
pure  water  into  the  vagina  for  a  few  minutes,  a  solution  of  coal  tar 
may  be  used,  or  a  decoction  of  walnut-leaves,  tannin,  or  oak  bark,  or 
a  solution  of  alum  (5j  to  a  quart  of  water),  sulphate  of  zinc  (same 
strength),  sulphate  of  copper  (30  grains  to  a  quart),  or  a  very  weak  solu- 
tion of  salicylate  of  soda.  Instead  of  injections  it  has  been  proposed 
to  apply  astringents  or  slight  caustics  in  the  form  of  ointments  or 
powders.  The  action  of  ointments  is  uncertain,  and  the  presence  of 
grease  in  the  vagina  is  not  favorable  to  the  cure  of  leucorrhoea.  It 
is  different  with  powders  :  they  absorb  the  fluid  or  are  gradually  dis- 
solved, and  so  the  tissues  in  contact  with  the  solution  are  affected 
continuously.  The  subnitrate  of  bismuth  is  the  best,  and  the  way  to 
apply  it  is  to  powder  the  diseased  surfaces  with  it  through  the  specu- 
lum. Sometimes  bags  filled  with  inert  and  astringent  powders  are 
introduced,  or  they  may  be  placed  on  a  tampon  of  cotton  wool.  The 
latter  is  one  of  the  best  ways,  I  prefer  it  to  soaking  the  pledget  in  an 
astringent  or  caustic  solution  because  it  acts  simultaneously  as  an 
absorbent  and  modificator  :  I  confess,  however,  that  I  do  not  much 
hke  leaving  any  foreign  body  in  the  vagina;  but  I  except  tampons 
saturated  in  a  glycerole  of  tannin  (gr.  30  to  5ij  of  tannin  to  glycerine 
5j)-  The  solubility  of  tannin  in  glycerine,  and  the  absorption  of  the 
glycerine  by  the  vaginal  mucous  membrane  render  this  application, 
which  was  first  suggested  by  Demarquay,^  very  efficacious.  After 
cleansing  the  vagina  thoroughly  introduce  a  large  tampon  wrung 
out  of  hot  water  and  then  saturated  with  the  glycerole  and  repeat 
every  two  or  three  days.  It  is  better  still  to  pour  one  or  two 
spoonfuls  of  this  glycerole  into  the  vagina  through  a  Pergusson's 
speculum  and  afterwards  introduce  a  tampon  of  dry  cotton  wool  which 
the  patient  can  remove  the  next  morning  and  then  make  a  vaginal  in- 
jection. It  is  still  easier  to  modify  the  mucous  membrane  by  painting 
with  a  brush.  A  solution  of  tincture  of  iodine  (1  in  5, 10  or  20)  may 
be  used,  or  tannin  or  glycerole  of  tannin  of  the  same  strength,  or 
peroxychloride  of  iron  or  a  solution  of  nitrate  of  silver  (  1  in  30,  20 
or  15)  applied  every  two  days. 

The  same  medication  is  applicable  to  uterine  leucorrJioea  ;  only  it  is 
more  difiicult  to  apply  caustic  to  this  mucous  membrane  and  to  make 
it  penetrate  into  the  follicles.  The  following  method  is  the  best :  in 
the  first  place  the  mucus  must  be  expelled  from  the  uterine  cavity. 
To  do  this  I  compress  the  cervix  with  the  speculum,  and  sometimes 
the  body  simultaneously  by  abdominal  pal|)ation;  or  I  direct  a  small 
douche  on  the  cervix  ;  or  after  having  used  the  sound  to  ascertain  the 
direction  of  the  cervico-uterine  canal,  I  introduce  a  fine  brush  or  inject 
tepid  water  by  means  of  a  hollow  sound,  continuing  to  do  so  suffi- 
ciently long  to  let  the  cavity  be  thoroughly  cleansed,  i.  e.  if  the  orifice 
is  large  enough  to  allow  the  water  to  pass  back  into  the  vagina.     If 

'  De  la  Glycerine  et  de  ses  applications  a  la  medecine  et  a  la  chirurgie. 
Paris,  1863. 


588  UTERINE    DISEASES    IN    DETAIL 

the  OS  is  not  large  enough  it  must  first  of  all  be  enlarged.  The  os  and 
cervical  canal  should  be  suificiently  enlarged  to  expose  the  mucous 
membrane  of  the  cervix.  We  are  then  sure  of  reaching  the  sources  of 
the  leucorrhoeic  secretion  vrith  the  caustic.  After  these  preliminary 
preparations  I  introduce  a  brush  covered  with  caustic  into  the  cavity 
of  the  organ  turning  it  in  various  directions  so  as  to  reach  the  whole 
surface. 

When  the  leucorrhcea  is  situated  in  the  cervical  portion  and  is  of 
sufficiently  long  standing  to  have  produced  hypertrophy  of  the  cervical 
glands  more  must  be  done :  in  such  circumstances  we  cannot  dilate 
the  raucous  membrane  sufficiently  nor  cleanse  it  thoroughly,  nor  yet 
reach  the  follicles  and  excretory  canals  of  the  rugged  surface 
(Fig.  334)  with  the  caustic.  I  therefore  have  recourse  to  a  small 
preliminary  operation  which  I  often  employ  in  the  treatment  of  fol- 
licular granulations  of  the  tonsils,  palate  and  pharynx  :  I  make 
numerous  scarifications  in  various  directions  over  the  whole  of  this 
rough  surface,  either  with  an  ordinary  scarificator,  a  narrow  convex 
or  concave  tenotome  knife,  or  with  a  small  lancet.  I  wait  till 
the  slight  hsemorrhage  is  arrested  :  I  then  wash  the  cervix  with 
very  hot  water  to  stop  the  hsemorrhage  and  to  cleanse  the  surface 
of  the  cavity,  after  which  I  apply  a  caustic  solution.  If  these 
caustic  solutions  are  insufficient,  or  if  the  leucorrhcea  is  compli- 
cated by  ulcerations,  granulations  or  an  engorgement  of  the  neck, 
I  substitute  the  solid  caustic  or  even  the  actual  cautery  (a  fine 
cautery  like  the  bill  of  a  bird  or  a  knife),  which  T  apply  in  various 
directions  in  the  most  tumefied  portion  of  the  cervical  mucous  mem- 
brane, taking  care  to  protect  the  other  portions  by  Recamier^s  large 
curette,  to  prevent  vicious  cicatrices  which  contract  and  obliterate  the 
cervix  when  the  cauterisation  has  affected  the  whole  periphery  of  the 
cervical  cavity  (lamentable  cases  of  which  I  have  seen). 

Huguier^  was  the  first  to  recommend  making  scarifications  before 
cauterising,  in  order  to  ensure  the  action  of  the  caustic  on  the  mucous 
membrane  of  the  cervix :  and  I  can  certify  that  it  is  one  of  the  best 
means  of  curing  this  membrane. 

The  difficulty  of  painting  the  uterine  cavity  when  the  leucorrhcea  is 
from  the  mucous  membrane  of  the  hocly  has  led  to  the  use  of  caustic 
injections. 

Fine  vulcanite  uterine  sounds  are  used^  or  india-rubber  sounds  into 
which  the  small  cannula  of  a  syringe  is  fitted  (Fig.  199,  page  319). 
We  must  make  sure  of  two  things :  1,  that  the  sound  moves  freely  in 
the  cervico-uterine  orifice,  and  that  the  fluid  when  gently  injected 
returns  easily  by  the  neck  and  falls  into  the  vagina  ;  2,  that  there  is 
no  trace,  I  do  not  say  of  metritis,  but  of  inflammation  of  the  annexes, 
perimetritis  or  pelvic  peritonitis.  I  often  prefer  cauterising  with  the 
solid  caustic,  with  a  brush  moistened  and  rolled  in  powdered  nitrate 
of  silver  applied  several  times  to  the  fundus.  This  cauterisation  when 
well  applied  is  very  successful.  No  leucorrhcea,  however  abundant, 
purulent,  or  chronic  withstands  this  treatment.  To  sum  up  :  the  os 
'   Gazette  des  Hopitaux,  1819. 


LEUCOEEHCEA    AND    UTERINE    CATARRH 


589 


must  be  large  or  well  dilated  and  quite  free,  there  must  be  no  flexion 
of  the  body  on  the  cervix  preventing  the  passage  of  the  mucus  from 


Fig.  334. — Ti-ansverse  ramifications  of  the  arhor  vita  in  the  cervical  cavity,  to 
show  the  uneven  surfaces  of  this  cavity  and  the  difficulty  there  is  in  reach- 
ing the  diseased  follicles  in  cases  of  leucorrhoea. 

the  one  into  the  other,  nor  must  there  be  any  inflammation  either 
uterine  or  peri-uterine^  or  even  strong  congestion  of  the  organ ;  the 
menses  should  have  ceased  a  week  previously,  so  that  the  monthly 
congestion  may  have  quite  disappeared ;  lastly,  a  general  treatment 
should  have  been  followed  and  simple  intra-utcrinc  injections  made 
with  applications  of  less  energetic  medicaments  such  as  tincture  of 
iodine,  iodoform  or  tannin,  to  test  the  sensitiveness  of  the  mucous 
membrane,  or  to  see  whether  these  milder  topics  are  not  sufficient. 
Usually  I  apply  powdered  nitrate  of  silver  to  the  fundus.     Unless 


590.  UTERINE    DISEASES   IN   DETAIL 

the  OS  is  unusually  large  I  first  dilate  it  with  a  sponge  tent  (Fig.  136, 
p.  149);  then  I  wash  it  with  very  hot  water  and  carbolic  acid,  or 
salicylate  of  soda;  and  then  holding  the  cervix  with  tenaculum  hook 
forceps  I  apply  successively  three  or  four  brushes  moistened  in  water 
and  rolled  in  powdered  nitrate  of  silver  to  the  uterine  fundus,  so  as  to 
be  sure  that  the  whole  surface  of  the  mucous  membrane  has  been 
reached  (Fig.  201,  p.  221). — Immediately  afterwards  the  patient  takes 
an  emollient  bath,  making  injections  all  the  time,  or  she  makes  injec- 
tions on  the  bidet.  She  should  be  confined  to  bed  for  a  fortnight,  con- 
tinuing the  baths  and  injections.  When  the  leucorrhoea  is  of  long 
standing  and  so  abundant  that  this  mode  of  cauterisation  seems  insuffi- 
cient, 1  use  the  crayon.  After  having  used  the  sound  to  ascertain  the 
direction  of  its  cavities,  I  introduce  the  crayon  by  means  of  forceps, 
or  a  porte-crayon  furnished  with  a  piston  (Figs.  202,  203),  leaving  it 
in  the  uterine  cavity  by  opening  the  forceps,  or  pushing  the  piston 
and  then  withdrawing  the  instrument  gently. 

It  is  needless  to  say  that  the  fragment  of  nitrate  of  silver  left  is 
sometimes  extremely  small,  and  that  its  size  should  vary  with  the  in- 
tensity of  the  malady  and  the  more  or  less  favorable  conditions  for 
applying  it.  A  tampon  saturated  with  salt  water  should  be  introduced 
into  the  vaginal  cul-de-sac  close  to  the  cervix,  and  care  be  taken  to 
prevent  the  development  of  inflammation.  Immediately  after  the 
operation  the  pain  is  alleviated  by  general  and  local  antispasmodics, 
enemata,  baths  and  vaginal  irrigations,  which  when  necessary  may  be 
prolonged  for  several  hours  and  continued  till  the  next  monthly 
period. 

I  have  never  seen  a  case  of  leucorrhoea  withstand  this  treatment 
combined  with  the  other  means  already  mentioned,  and  1  have  proved 
by  experience  that  it  is  unattended  with  any  danger  for  reasons 
already  explained  (p.  224) ;  that  menstruation  has  become  normal, 
that  conception  has  taken  place  and  has  been  followed  by  normal 
pregnancy  and  delivery. 

Other  gynecologists  have  acknowledged  the  usefulness  of  this  mode 
of  cauterisation  and  its  innocuity  when  applied  according  to  the  rules 
I  have  laid  down.  Braun  of  Vienna  has  invented  a  small  instrument 
consisting  of  a  cannula  of  vulcanite  furnished  with  a  piston  to  precipi- 
tate the  nitrate  of  silver  into  the  cavity  in  the  way  1  first  suggested. 
I  have  also  received  letters  from  a  great  number  of  physicians  telling 
me  of  the  success  they  have  obtained  from  the  use  of  this  means  in 
the  treatment  of  obstinate  leucorrhoea.^ 


Hypeetrophy  and  Atrophy 

In  the  first  place,  common  hypertrophy  must  be  distinguished  from 
special  hypertrophy. 

1.   Common  hypertrophy  afi'ects  all  the  elements  at  once,  it  is  true 

'  Laroyenne  of  Lyons  has  also  adopted  this  means  ;  he  uses  a  crayon 
composed  of  equal  parts  of  nitrate  of  silver  and  nitrate  of  potash.  Bianchard 
{Theses  de  Paris,  1873). 


HYPERTROPHY    AND   ATROPHY  591 

uterine  hypertrophy.  It  may  be  total,  i.e.  extending  over  the  whole 
organ  (body  and  neck) ;  or  partial  (hypertrophy  of  the  body,  hyper- 
trophy of  the  neck) ;  or  even  be  limited  to  one  portion  of  the  body  or 
neck  ;  when  the  body  is  affected,  it  may  be  limited  to  the  anterior  or 
posterior  segment  or  one  of  the  cornua^  and  in  the  neck  it  may  be 
confined  to  the  supra-  or  sub-vaginal  portion,  or  to  the  anterior  or 
posterior  segment,  and  even  in  each  of  these  segments,  the  hyper- 
trophy may  be  limited  to  the  vaginal  or  to  the  uterine  portion  of  the 
one  or  other,  to  one  of  the  cervical  lips,  or  to  one  of  the  columns  of 
the  cervico-uterine  isthmus. 

2.  Special  hypertrophy  or  hypertrophy  of  the  tissue  affects  only  one 
or  more  of  the  histological  elements  of  the  organ.  It  may  be  general, 
i.e.  extending  over  all  the  portions  of  the  affected  tissue  [e.g.  hyper- 
trophy of  the  tissue  proper,  hypertrophy  of  the  mucous  membrane, 
hypertrophy  of  the  vascular  economy,  &c.) ;  or  local,  i.e.  limited  as  to 
seat  as  well  as  to  tissue  (giving  rise  to  fibromata,  follicular  polypi, 
vascular  tumours,  fungosities,  granulations).  Nevertheless,  although 
this  division  is  the  exact  expression  of  the  diversity  of  the  anatomical 
alterations,  I  think  it  is  sufficient  in  practice  to  distinguish  total  from 
partial  hypertrophy,  and  for  the  latter  specially  to  study  hypertrophy 
of  the  neck.  Partial  hypertrophy  is  more  common  than  total  hyper- 
trophy, that  of  the  cervix  is  more  common  than  that  of  the  whole 
uterus,  that  of  the  mucous  membrane  or  of  some  special  element  of 
that  membrane  is  more  frequent  still.  Special  or  histological  hyper- 
trophy is  more  frequent  than  common  hypertrophy.  When  the 
elements  of  the  mucous  membrane  are  affected,  excrescences  are  pro- 
duced known  under  the  names  of  granulations,  fungosities,  follicular 
cysts,  mucous  polypi,  vascular  tumours  ;  when  the  elements  of  the 
tissue  proper  are  affected,  polypi,  fibroids,  &c.,  are  produced.  The 
former  having  common  symptoms  requiring  analogous  treatment  will 
be  described  in  another  chapter.  The  latter,  which  are  very  much 
localised  and  also  often  very  much  developed,  assume  the  character  of 
true  organic  alterations,  and  in  this  way  become  the  source  of  special 
indications  and  will  be  studied  in  another  section. 

Here  therefore  I  shall  only  describe  common  hypertrophy  or  hyper- 
trophy properly  so  called,  that  which  affects  all  the  elements  of  the 
organ  and  which  attacks  the  whole  uterus  or  one  of  its  two  principal 
segments.  The  first  is  total  hypertrophy  of  the  womb,  the  second 
pjartial  hypertrophy  of  the  cervix. 

I. — General  Hypertrophy  of  the  Womb 

1.  Hypertrophy  proper. — In  my  lectures  I  have  taught  for  a  long 
time  that  general  hypertrophy  of  the  uterus  should  be  admitted,  and  I 
have  shown  preparations  in  support  of  the  opinion.  I  have  distin- 
guished hypertrophy  not  only  from  inflammation,  congestion  and 
fluxion  which  are  accompanied  by  pain,  redness,  infiltration,  vascular 
injection  and  general  phenomena ;  but  also  from  engorgement  which 
is  less  consistent,  from  oedema  which  is  soft,  and  from  the  irregular 
and  hard  tumefactions  of  commencing  cancer.    In  general  hypertrophy 


592  UTERINE    DISEASES    IN   DETAIL 

the  uterus  preserves  its  normal  aspect,  but  is  more  voluminous ;  one 
would  say  a  womb  beloDging  to  a  woman  of  colossal  dimensions. 
Simpson  has  given  a  perfect  description  of  this  state.  Hypertrophy- 
is  always  an  acquired  condition  resulting  from  morbid  action,  from  an 
exaggeration  of  normal  nutrition.  It  is  a  morbid  increase  in  the  size 
of  the  uterus  and  of  the  elements  of  its  normal  tissues.  Eeal  hyper- 
trophy is  essential  or  idiopathic,  that  which  Scanzoni  designates  by  the 
name  of  primary,  which  is  a  disease  in  itself  requiring  special  treat- 
ment, the  basis  of  which  is  resolvent  medication.  Essential  hyper- 
trophy is  seldom  primary,  i.  e.  it  is  rarely  developed  unless  a  pre-exist- 
ing morbid  state  of  the  uterus  has  brought  the  organ  into  a  condition 
in  which  hypertrophy  may  be  developed. 

The  two  most  favorable  conditions  for  the  development  of  hyper- 
trophy are  congestion  and  defective  involution.  When  congestion  is 
repeated  or  prolonged  it  introduces  into  the  material  conditions  of  the 
organ  the  inevitable  changes  always  produced  by  hyperemia  in  the  organs 
aflf cted  by  it,  and  in  particular  hypertrophy.  It  is  in  the  nature  of  long 
continued  hypersemia  to  stimulate  nutrition  in  the  tissues  which  are  the 
seat  of  it.  Chronic  inflammation  may  produce  the  same  result ;  but  it 
is  more  apt  to  induce  engorgement  or  induration :  something  more  is 
required  to  bring  about  hypertrophy.  As  to  defective  involution,  it 
leaves  the  organ  hypertrophied  rather  than  produces  hypertrophy  :  if 
absorption  is  interrupted  while  the  normal  work  of  nutrition  continues 
in  a  uterus  the  retrograde  evolution  of  which  is  suspended,  the  size  of 
the  uterus  will  not  decrease,  the  thickness  of  its  walls  will  be  pre- 
served, the  density  of  its  tissue  and  the  mass  of  its  textular  elements 
will  persist,  and  it  will  continue  in  this  condition,  i.  e.  it  will  be 
hypertrophied.  In  the  former  mode  of  production  the  hypertrophy  is 
active,  in  the  second  it  is  passive.-^ 

It  is  very  seldom  that  the  whole  uterus  is  equally  hypertrophied, 
sometimes  the  mucous  membrane,  at  other  times  the  tissue  proper  is 
chiefly  hypertrophied.  Sometimes  it  is  accompanied  by  enlargement 
of  the  cavity  of  the  organ,  like  excentric  cardiac  hypertrophy ;  this  is 
especially  the  case  when  a  foreign  body  occupies  this  cavity.  Some- 
times it  coincides  with  a  relative  diminution  of  this  cavity,  as  in  con- 
centric hypertrophy  of  the  heart;  there  is  then  often  partial  hyper- 
trophy of  the  tissue  proper  at  one  or  more  points,  e.  g.  the  formation 
of  fibroids.  I  have  recently  seen  a  lady  who  presented  a  case  of  this 
kind,  and  in  whom  the  uterine  cavity  measured  from  6  to  7  inches 
in  length. 

Diagnosis, — Individual  differences  of  size  and  excessive  congenital 
development  must  be  taken  into  account.  When  the  uterus  is  really 
hypertrophied   the  patient  experiences  a  feeling  of  discomfort  in  the 

^  West  describes  one  cause  of  uterine  hypertrophy  to  which  he  attributes 
great  importance,  but  which  seems  to  me  only  dependent  on  congestion  or  on 
repeated  fluxions  produced  by  immoderate  sexual  excitement.  The  cause  is  not 
so  much  excessive  coitus,  as  a  voluntar}^  imperfection  in  the  accomplishment  of 
this  act,  that  is  to  say,  copulations  repeated  too  frequently  but  which  are  always 
incomplete  and  congest  the  uterus  uselessly,  and  in  which  conception  cannot 
take  place. 


HYPERTROPHY  AND  ATROPHY  593 

pelvis  and  weight  on  the  perinseum,  without  either  heat  or  pain ;  there 
is  little  or  no  leucorrhceaj  sometimes  metrorrhagia^  at  other  times 
amenorrhoea.  Digital  touch  combined  with  palpation  shows  an  in- 
crease in  size  and  weight  with  prolapsus  or  deviation ;  examination  of 
the  cervix  by  speculum  confirms  these  facts;  the  sound  discloses  an 
increase  in  the  length  and  breadth  of  the  uterine  cavity  and  yet  no 
indication  of  tumour  either  sessile  or  pediculated.  The  principal 
symptoms  are :  on  the  one  hand  those  which  indicate  an  increase  of 
size,  and  on  the  other  hand  negative  characters.  For  the  organ  has 
increased  in  mass  and  volume,  the  number  and  dimension  of  its  con- 
stitutive elements  are  increased,  it  may  even  have  changed  its  form ; 
but  its  structure  has  not  become  modified,  nor  have  its  physiological 
or  pathological  properties  fundamentally  altered.  Tillaux  read  a  paper 
before  the  Societe  de  Ckirurgie}  describing  a  very  interesting  case  of  a 
nullipara  who  suffered  for  fifteen  years  from  prolonged  and  acute 
menorrhagia  to  which  she  succumbed  at  the  age  of  47,  and  which  was 
due  to  essential  varicose  hypertrophy  of  the  uterus  associated  with 
fibromata.  The  case  is  very  interesting  from  the  double  point  of  view 
of  the  size  that  the  organ  had  acquired  and  the  vascular  character  of 
the  hypertrophy,  and  affords  me  an  opportunity  of  here  describing  the 
differential    diagnosis    of   symptomatic    and  essential  hypertrophy  : 

1.  Symptomatic  hypertrophy  (especially  from  a  fibroma)  is  produced 
by  a  double  influence.  As  a  foreign  body  the  fibroid  provokes  con- 
tractions for  its  expulsion  from  the  uterine  cavity  which  are  unsuc- 
cessfully repeated  till  the  womb  becomes  hypertrophied.  The  fibroid 
by  obstructing  the  orifice  or  incompletely  determining  its  occlusion 
may  cause  considerable  menstrual  retention ;  a  portion  of  the  con- 
tents may  at  first  escape  by  overflow,  but  enough  always  remains 
to  distend  the  organ  or  to  provoke  contractions ;  clots  are  expelled, 
but  every  expulsive    effort  is   an    additional    cause  of   hypertrophy  : 

2.  Hypertrophy  proper  does  not  require  for  its  development  the 
presence  of  a  foreign  body  in  the  uterus.  It  is  not  so  uncommon  as 
is  believed  ;  cases  of  special  hypertrophy,  of  fibromata  especially,  occur 
frequently  in  girls  and  nulliparae.  Common  and  total  hypertrophy, 
although  not  so  general,  is  sometimes  seen.  It  is  known  by  the 
absence  of  any  foreign  body,  or  any  cause  which  could  have  determined 
frequent  contractions  of  the  uterus.  In  Tillaux's  case  the  hypertrophy 
was  idiopathic :  it  was  common  and  total,  having  affected  all  the  ele- 
ments and  the  whole  organ ;  only  it  was  localised  more  strongly  on 
three  points  of  the  tissue  proper,  where  it  gave  birth  to  three  fibro- 
mata. One  of  the  most  interesting  circumstances  in  Tillaux's  case 
was  that  of  considerable  periodical  variations  in  the  volume  of  the 
tumour  :  the  enormous  increase  of  the  uterus  before  menstruation  and 
the  sensibly  diminished  size  of  the  organ  afterwards.  The  uterus  was 
congested  at  every  monthly  period  as  if  it  were  really  pregnant.  I 
have  seen  this  very  often  though  in  a  less  degree.  This  great  varia- 
tion in  size  probably  depends  on  hypertrophy  of  the  sinuses  and  their 
enormous  dilatation.     It  might  also  probably  serve  as  an  clement  of 

1  Meeting?  of  the  18th  November,  1868. 

38 


594  UTEEINE    DISEASES    IN    DETAIL 

differential  diagnosis  between  the  hypertrophy  which  affects  simulta- 
neously all  the  organic  systems  of  the  uterus  and  the  vascular  economy 
exceptionally,  and  that  of  the  tissue  proper  in  particular. — Lastly, 
these  periodical  variations  of  size,  due  to  the  enormous  congestion  of 
the  uterine  vessels,  ought  to  be  distinguished  from  those  which  depend 
on  incomplete  menstrual  retention.  The  essentially  distinctive  sign 
between  these  two  morbid  states  seems  to  me  to  be  the  absence  of 
muscular  contractions  in  the  former,  the  frequent  appearance  of  ex- 
pulsive efforts  in  the  latter ;  the  acute  pains,  the  uterine  colics  expe- 
rienced by  patients  in  the  latter  case,  will  be  distinguished  easily  from 
the  continuous  dull  pain  caused  by  slow  and  persistent  congestion  of 
the  uterus. 

As  to  the  definite  results  of  menstrual  retention  on  uterine  hyper- 
trophy, what  occurs  in  complete  retention  must  be  distinguished 
from  what  takes  place  when  retention  is  incomplete.  In  the  former 
the  uterus  is  sometimes  considerably  distended,  and  the  thickness  of 
its  walls  is  not  developed  in  proportion  to  the  capacity  of  its  cavity ; 
the  continuous  accumulation  of  blood  which  induces  hsematometria 
distends  the  organic  tissue,  which  gradually  loses  its  powers  of  con- 
traction at  the  same  time  that  its  walls  become  attenuated.  In  the 
latter,  on  the  contrary,  the  uterus,  especially  the  muscular  tissue,  is 
always  hypertrophied.  The  coagulated  blood,  the  expulsion  of  which 
is  difficult  though  not  impossible,  acts  on  the  uterus  as  a  foreign  body, 
a  fibroma,  a  polypus,  a  mole ;  it  provokes  incessant  contractions,  de- 
termining hypertrophy,  particularly  hypertrophy  of  the  muscular 
tissue,  and  consequently  considerable  thickening  of  the  uterine  walls. 

Treatment. — Hypertrophy  is  best  treated  by  resolvent  medication, 
including  local  resolvents,  strictly  so  called,  as  well  as  caustics  poten- 
tial or  actual ;  and  all  general  means,  cutaneous  and  intestinal  revul- 
sives, alteratives  (iodine,  mercury,  arsenic),  vapour  baths,  hydropathy, 
and  cura  famis.  It  must,  however,  be  remembered  that  a  malady 
like  hypertrophy  takes  a  long  time  to  cure.  The  treatment  is  long 
and  does  not  always  succeed  completely.  Portunately  health  may  be 
restored  without  complete  resolution  of  the  hypertrophy.  When  reso- 
lution cannot  be  obtained  we  must  be  satisfied  with  palliatives,  e.g.  a 
pessary  or  perinseal  pad  kept  in  place  by  straps  under  the  thighs  and 
a  belt  with  braces  such  as  is  used  in  cases  of  prolapsus. 

3.  Arrested  Involution 
I  have  reserved  a  special  description  for  a  form  of  hypertrophy  not 
uncommon  according  to  Simpson  •}  I  mean  hypertrophy  due  to  the 
arrest  of  the  retrograde  evolution  of  the  uterus  after  delivery.  I  have 
said  that  it  is  very  important  to  recognise  these  two  phenomena  in 
interpreting  uterine  diseases.  The  retrograde  evolution  of  the  uterus, 
which  has  been  well  studied  in  Germany  and  especially  in  England,  is 
effected  by  gradual  absorption  of  the  hypertrophied  elements.  This 
process  comprises  two  others  :  a  primary  modification,  the  fatty  infil- 
tration of  the  hyperplastic  or  hypertrophic  muscular  fibres,  or  rather 
"  Op.  cit.,  p.  585. 


HYPEETEOPHY    AND   ATEOPHY 


595 


the  substitution  of  fat  for  the  elements  of  muscular  fibre,  which  brings 
back  this  fibre  to  an  elementary  form  more  favorable  to  its  absorption 
and  to  its  definite  disappearance ;  and  a  second  act  of  decomposition, 
the  successive  absorption  of  the  fibres  which  have  undergone  this  fatty 


Fig.  335.  Fig.  336.  Fig.  337. 

Fig.  335. — Fibres  of  the  pregnant  uterus. 
Fig.  336. — Fatty  infiltration  of  muscular  fibres  and  gradual  absoi-ption  of  their 

elements  during  the  period  of  involution,  i.e.  recurrence  to  the  state  of 

vacuity  after  gestation. 
Fig.  337. — Eetum  of  the  muscular  fibres  to  the  size  they  present  when  the 

uterus  is  in  a  state  of  vacuity. 

infiltration,  and  the  gradual  return  of  the  organ  to  its  histological 
composition  and  to  its  normal  dimensions.  This  process,  which  is 
regressive,  resorbent  and  retractive,  is  designated  in  England  by  the 
term  involution.  Simpson  applied  the  term  subinvolution  to  defective 
and  superinvolution  to  excessive  involution.  In  the  former  case  the 
uterus  remains  partly  what  it  was  during  pregnancy  or  after  delivery  : 
now,  in  the  unimpregnated  condition  this  state  is  one  of  real  hyper- 
trophy. In  the  latter  case  the  uterus  exceeds  the  hmits  of  the  normal 
diminution  in  size,  becoming  quite  small  and  atrophied.  The  hyper- 
trophy proceeding  from  defective  retrograde  evolution  is  pathological 
in  its  permanence,  but  physiological  in  its  origin. 

We  know  nothing  of  the  causes  strictly  so-called  which  arrest 
regressive  transformation,  absorption  and  involution  of  the  uterine 
walls.  The  occasional  circumstances  which  are  most  favorable  to  the 
action  of  these  essential  causes  are  :  metritis,  fatigue  experienced  by 
the  uterus  in  women  who  rise  too  soon  after  delivery,  especially 
repeated  pregnancies  and  abortions. 

Diagnosis. — This  malady  is  not  very  uncommon.  Simpson  men- 
tions  three  cases,  and  I  have  seen  several  others  that  were  very 
characteristic.  It  may  be  suspected  then  if,  in  the  absence  of  signs  of 
inflammation  or  congestion,  the  patient  experiences  after  the  birth  of 


596 


UTEEINE    DISEASES    IN  DETAIL 


her  last  child  menstrual  disorders,  a  feeling  of  weight  and  fulness  in 
the  pelvis,  in  short  most  of  the  rational  symptoms  of  uterine  hyper- 
trophy. We  ascertain  by  direct  examination  the  absence  of  a  distinct 
tumour  while  the  volume  of  the  uterus  is  increased  in  every  direction 
equally,  recalling  the  size  of  the  uterus  at  the  third  month  of  gesta- 
tion, the  sound  showing  the  cavity  to  be  9  or  10  centimetres  or  more. 


Fig.  338. — Uterus  of  a  woman  who  died  immediately  after  delivery.  This 
figure  shows  the  volume  which  the  organ  may  preserve  when  involution  is 
arrested.  It  is  anteflesed ;  in  other  women  it  is  sometimes  retroflexed 
(fig.  291,  p.  435). 

Defective  involution  always  coincides  with  softening  and  may  be  com- 
plicated by  flexion,  prolapsus,  permanent  congestion  and  even  chronic 
inflammation. 

There  are  two  principal  characteristics  which  will  especially  help  us 
in  making  a  diagnosis  and  in  distinguishing  the  arrest  of  involution  from 
other  kinds  of  hypertrophy  :  the  first  is  the  uniform  softness  of  the 
uterine  tissue,  combined  with  the  wine-red  colour  and  other  character- 
istics of  gestative  congestion ;  the  second  is  the  extreme  laxity  of  the 
ligaments  and  consequent  tendency  to  prolapsus,  or  at  least  the  indif- 
ference of  position  or  direction  of  the  uterus.  This  distinction  is 
important,  since  the  treatment  of  this  kind  of  hypertrophy  consists 
less  in  the  use  of  resolvents  strictly  speaking  than  in  the  application  of 
means  capable  of  stimulating  muscular  contractions,  and  inducing 
involution ;  I  have  frequently  seen  this  lead  to  cure  in  cases  in  which 
the  disease  (for  long  misunderstood)  had  been  treated  as  simple  con- 
gestion or  chronic  hypertrophic  metritis. 

Trealmeul.—S[m])son  recommends  the  use  of  local  antiphlogistics 
in  the  acute  form  of  arrested  retrograde  evolution,  asserting  that  such 
treatment  effects  absorption ;  but  I  think  he  confounds  hypertrophy 
resulting  from   defective  evolution   with  the  cause  itself  which  pro- 


HYPERTEOPHY    AND    ATROPHY  597 

duces  it  and  which  temporarily  suspends  the  contraction  of  the  organ; 
in  fact  he  adds  that  all  traces  of  inflammation  disappear  with  the  use 
of  these  means  and  that  their  disappearance  is  followed  by  rapid 
improvement. 

Therefore,  he  adds,  even  if  all  inflammation  seems  to  be  extin- 
guished, and  when  the  results  only  remain,  we  often  find,  without 
knowing  why,  that  local  antiphlogistic  treatment  has  the  effect  of 
determining  absorption  of  the  hypertrophied  organ,  and  of  finally 
restoring  it  to  its  normal  condition.  Consequently  if  the  patient  is 
not  too  weak  we  begin  by  the  application  of  ten  or  twelve  leeches  to 
the  vaginal  portion  of  the  cervix,  or  the  perinseum,  or  round  the  anus. 
But  in  these  cases  and  in  the  most  chronic  form  the  same  effects  are 
obtained  from  the  application  of  counter-irritants  to  the  external 
surface  of  the  abdomen  or  sacrum,  such  as  antimonial  ointment, 
croton  oil,  tincture  of  iodine;  but  cantharides  is  the  best  stimulator 
of  absorption  especially  in  the  chronic  form  of  the  disease  and  when 
the  bladder  is  not  irritable.  A  series  of  small  blisters  may  be  applied 
to  the  lower  portion  of  the  abdomen  every  two  or  three  days  till  the 
volume  of  the  uterus  is  visibly  diminished.  Simpson  used  to  make 
them  the  size  of  a  five-shilling  piece  and  apply  one  every  few  days. 
Whilst  absorption  is  stimulated  by  the  application  of  counter-irritants 
to  the  cutaneous  surface,  the  same  action  may  be  promoted  by  the 
application  of  mercurial  ointment  to  the  vagina,  or  iodide  of  lead,  or 
bromide  of  potassium,  in  the  form  of  pessaries.  Local  applications, 
however,  are  not  sufficient  j  resolvents  should  also  be  administered 
internally.  Amongst  these  the  most  efficacious  are  the  iodide  and 
bromide  of  potassium.  Simpson  preferred  the  bromide  :  it  has  this 
advantage  over  the  iodide  that  it  can  be  administered  for  a  much 
longer  time  without  causing  marasmus  ;  it  is  tonic  and  perhaps  the 
best  resolvent  in  the  whole  pharmacopoeia ;  it  is  also  a  sedative  to  the 
genital  organs.  In  such  cases  from  3  to  7  grains  may  be  given  three 
times  a  day,  indeed  the  dose  may  be  raised  to  90  grains  a  day. 
Sometimes  patients  suffering  from  this  kind  of  hypertrophy  are 
anaemic  and  feeble.  When  this  is  so  recourse  should  be  had  to 
resolvents  of  iron,  manganese  and  other  tonic  metals,  either  alone  or 
associated  with  more  specific  remedies  in  order  to  improve  the  general 
health  of  patients  by  hygienic  measures.  Lastly,  when  the  uterus 
does  not  respond  to  any  indirect  stimulus  we  may  try  Simpson's  plan 
of  introducing  small  sponge  tents  into  the  uterus  or  an  intra-uterine 
pessary.  We  may  provoke  a  tendency  to  hypertrophy  in  the  uterus 
and  then  take  advantage  of  the  tendency  of  the  organ  to  undergo 
molecular  fatty  substitution  and  retrograde  evolution,  as  soon  as  the 
artificial  stimulus  is  withdrawn,  and  by  the  use  of  the  various  resol- 
vents already  mentioned,  rest,  counter  irritants,  and  bromide  deter- 
mine such  absorption  so  actively,  that  the  uterus  is  at  last  reduced  to 
its  normal  dimensions.  I  have  also  found  the  use  of  ergot  and  elec- 
tricity beneficial,  as  well  as  iron  baths,  sea  bathing,  stimulating  fric- 
tions, hydropathy,  &c.  Simpson  says  that  in  some  obstinate  cases  he 
has  been  obliged  to  repeat  this  treatment  by  irritation  and  artificial 


598  UTERINE    DISEASES    IN    DETAIL 

hypertrophy  of  the  organ  from  time  to  time  before  obtaining  a  com- 
plete cure. 

II.  Partial  Hypertrophy  of  the  Cervix 

The  hypertrophy  which  is  limited  to  the  cervix  is  characterised 
especially  by  the  elongation  of  this  portion  of  the  organ.  It  has  often 
been  mistaken  for  prolapsus.  It  must  not^  however,  be  thought  that 
this  uterine  displacement  is  always  simulated  by  hypertrophic  elonga- 
tion of  the  cervix.  Huguier^  who  deserves  the  credit  of  showing  the 
mistake  which  had  for  long  been  made  with  regard  to  supposed  proci- 
dentia^ has  given  examples  of  complete  prolapsus  uteri  without  elon- 
gation of  the  cervix,  and  has  published  woodcuts  of  them.^  On  the 
other  hand  we  cannot  believe  with  Veit  [Zeitschrift  f.  Geburts&.,'Bd.i, 
S.  144),  that  primary  hypertrophic  elongation  is  very  rare  and  that  this 
kind  of  hypertrophy  is  usually  consecutive  to  prolapsus ;  it  is  on  the 
contrary  the  hypertrophy  which  simulates  prolapsus ;  hypertrophy 
subsequent  to  descent  may  occur,  but  it  is  very  rare.  Hypertrophy 
may  affect  the  whole  of  the  cervix ;  but  usually  it  is  limited  to  one  or 
other  of  the  two  portions  of  this  organ,  sometimes  to  the  vaginal  or 
intra-vaginal  portion  situated  below  the  insertion  of  the  vagina,  some- 
times to  the  supra-  or  utero-vaginal  portion,  situated  above  this  inser- 
tion and  ending  in  the  isthmus  separating  the  cervix  from  the  body ; 
sometimes  even  it  is  insensibly  extended  to  the  latter.  The  former 
might  be  designated  by  the  name  of  cervico-vaginal  hypertrophy,  the 
latter  by  that  of  cervico-uterine  hypertrophy.  At  other  times  the 
hypertrophy  is  confined  to  one  of  the  segments,  anterior  or  posterior, 
or  to  one  portion  of  this  segment.  These  three  maladies  should  be 
studied  separately. 

These  difi'erent  kinds  of  hypertrophy  should  never  be  confounded  with 
cedematous  elongation  and  prolapsus  of  the  cervix  during  pregnancy, 
described  by  Gueniot,^  Scarlau,^  &c. 

1.  Suhvaginal  Hypertrophy  of  the  Cervix 
The  relative  length  of  the  two  portions  of  the  cervix  (vaginal  and 
supra-vaginal)  depends  in  some  women  on  the  height  of  the  vaginal 
insertion ;  but  in  addition  to  this  cause,  which  is  foreign  to  the  cervix, 
there  is  another  which  exceptionally  increases  the  projection  of  the 
cervix,  so  as  to  give  it  considerable  length.  The  proof  of  this  is  that 
in  virgins  we  often  see  the  cervix  (usually  conical)  several  centimetres 
long.  Bennet*  has  also  seen  the  cervix  in  virgins  nearly  9  centi- 
metres long,  resting  on  the  vulval  orifice  or  even  projecting  below  it, 
and  asserts  that  the  elongation  may  exist  congenitally  notwith- 
standing Huguier's  opinion,  and  in  spite  of  the  great  tendency 
of  the  uterus  and  cervix  to  become  hypertrophied  under  the  influence 
of  inflammation  or  even  of  simple  congestive  irritation.     He  has  seen 

'  Memoire  siir  les  allongements  hypertrojMques.  See  the  plate  taken  from 
Dupuytren's  museum.  Case  xii,  and  figure  3. 

2  Archives  de  viedecine,  April,  1872. 

3  Beitrdge  zur  Geburtsk.  u.  Gryndh.,  Bd.  ii,  Heft  1.  Berlin,  1872. 
*  Op.  cit.,  p.  10. 


HYPERTROPHY    AND   ATROPHY 


599 


several  cases  in  unmarried  women  when  no  inflammatory  action  of  any 
kind  could  be  discovered.  They  consulted  him  for  prolapsus,  the 
appearance  of  the  cervix  at  the  vulva  having  frightened  them  and  in- 
duced them  or  their  parents  to  seek  medical  advice.  The  congenital 
elongations  which  I  have  met  with  have  never  seemed  to  me  to  reach 
9  centimetres  in  length.  West  says  also  that  hypertrophy  of  the 
vaginal  portion  of  the  cervix  is  met  with  not  only  in  sterile  married 
women,  but  in  virgins,  that  it  may  be  so  serious  as  to  be  mistaken 
for  prolapsus,  the  cervix  appearing  at  the  vulva,  and  that  it  forms  an 
obstacle  to  marital  intercourse  causing  sterility. 

More  frequently  hypertrophy  of  the  cervix  follows  the  swelling 
produced  in  the  tissue  of  the  organ  by  the  persistence  of  the  modifica- 
tions accompanying  pregnancy,  and  is  the  result  of  defective  involu- 
tion of  the  uterus  after  delivery.  The  hypertrophy  may  even  be 
limited,  in  this  case,  to  one  of  the  cervical  lips,  usually  to  the  anterior ; ' 


Fig.  .339. —  Conical  hypertrophy  of  the  sub-vaginal  portion  (Huguier). 

as  a  rule  also  elongation  and  hypertrophy  of  the  cervix  follow  the 
swelling  produced  in  the  tissue  of  the  organ  by  the  persistence  of  con- 
gestion, inflammation  and  frequently  ulceration  of  the  mucous  mem- 
brane, which  is  itself  the  cause  of  the  long  duration  of  these  morbid 
states. 

Another  cause  requires  to  be  added  to  the  ulceration,  congestion  and 

*  Evory  Kennedy,  in  Dublin  Medical  Jonrnal,  1838. — Simon  of  Rostock  has 
also  published  a  remarkable  example,  with  three  drawings  {Monafsschrift  fiir 
Geburtsh.  u.  Frauenkranhheiten,  1864,  Bd.  xxiii,  S.  241). 


600 


UTEEINE    DISEASES   IN    DETAIL 


inflammation  and  to  the  swelling  which  accompanies  them,  in  order  to 
produce  hypertrophy :  the  special  tendency  of  the  uterus  to  hyper- 


FlG.  340. — Pyriform  hypertropliy  of  the  sub-vaginal  portion  (Huguier). 

trophy  requires  to  be  stimulated ;  for  a  congested  and  swollen  cervix 
equal  in  size  to  that  of  a  hypertrophied  cervix  may  remain  after  several 
years  soft  and  simply  engorged.  There  is,  however,  so  great  a  ten- 
dency towards  hypertrophy  in  the  uterus  that  the  eff'usion  of  plastic 
lymph  produced  by  inflammation  in  the  deep  tissues  becomes  organised ; 
the  elements  of  the  tissue  proper,  stimulated  by  the  persistence  of  the 
fluxionary  movement,  increase  in  size  and  multiply  ;  in  fact,  real  hyper- 
trophy supervenes,  which  may  survive  the  extinction  of  inflamma- 
tory phenomena. 

It  is  very  easy  to  distinguish  congenital  from  morbid  hypertrophic 
elongation  of  the  vaginal  portion  of  the  cervix.  Congenital  hyper- 
trophy is  rare,  the  elongated  cervix  is  regularly  cylindrical  or  conoid ; 
its  consistency  is  relatively  soft;  in  appearance  it  is  normal, presenting  no 
lesion,  or  only  superficial  alterations,  unless  it  has  really  become  diseased. 
Morbid  hypertrophy  is  common,  the  elongated  cervix  is  irregular, 
not  only  conoid  but  globular,  the  lower  portion  sometimes  spreading 
out  when  the  latter  is  particularly  affected  by  the  hypertrophy ;  it  is 
congested,  inflamed  or  even  ulcerated,  and  consequently  it  is  hard, 
painful,  sometimes  bleeding  and  requires  energetic  treatment. 


HYPERTEOPHY   AND    ATEOPHY 


601 


With  regard  to  cervical  hypertrophy  consecutive  to  inflammation  as 
well  as  hypertrophy  of  the  whole  organ  due  to  defective  retrograde 


Fig.  341.  Fig.  342. 

Fig.  341. — Hypertrophy  of  the  sub-vaginal  poi-tion  affecting  the  two  lips  un- 
equally, with  e version  of  the  lips  and  ectropion  of  the  arbor  vitiS  (Huguier). 

Fig.  342. — Hypertrophy  and  procidentia  of  the  vaginal  portion  affecting  both 
lips,  which  converge  towards  the  cervical  cavity  ;  the  anterior  lip  is  more 
hypertrophied  in  its  centre,  the  posterior  in  its  whole  extent  and  at  its 
extreme  points  ;  hypertrophic  polypi  coming  from  the  central  column  of 
the  anterior  lip  (Barnes,  p.  638). 

evolution,  we  must  take  into  account  one  important  circumstance,  viz. 
the  time  which  has  elapsed  between  a  delivery  or  abortion  and  the 
development  of  inflammation;  for  the  hypertrophic  character  of  the 
malady  is  frequently  due  to  this  circumstance.  The  nearer  the  in- 
flammation is  to  the  period  of  delivery  or  abortion  the  more  con- 
siderable the  consecutive  hypertrophy  wnll  be,  because  the  organ  has 
been  seized  at  the  time  when  regressive  absorption  had  not  been  able 
to  produce  any  efl'ect  on  it.  Whether  hypertrophy  of  the  cervix  may 
or  may  not  be  dependent,  like  that  of  the  whole  organ,  on  arrested 
retrograde  evolution  consecutive  to  delivery,  the  limitation  of  this 
hypertrophy  to  the  cervix  is  a  favorable  circumstance  in  the  prognosis  : 
it  is  always  easier  to  dissipate  cervical  hypertrophy,  whatever  its  origin 
be,  than  to  bring  back  the  hypertrophied  fundus  to  its  physiological 
state  and  to  its  normal  dimensions. 

Whether  congenital  or  morbid,  hypertrophy   gives  to  the  cervix 
varied  and  occasionally  singular  forms.     Sometimes  it  is  pointed  and 


602 


UTEEINE    DISEASES    IN   DETAIL 


conical  below  (Fig.  339),  the  os  being  at  the  extremity  of  the  cone  or 
on  one  of  its  surfaces  ;  sometimes  it  is  cylindrical,  globular  or  enlarged 

at  the  base  in  the  form  of  a  club 
(Figs.  342,  345).  Sometimes 
the  two  lips  are  equally  hyper- 
trophied  and  the  utero- vaginal 
OS  is  in  the  centre  (Figs.  343, 
345);  sometimes  they  are  une- 
qually hypertrophied  (Fig.  341), 
the  OS  being  on  one  or  other  of 
the  surfaces,  and  occasionally 
completely  hidden  by  the  more 
hypertrophied  lip.  Lastly,  when 
the  hypertrophy  has  chiefly  af- 
fected the  external  layers  of  the 
organ  the  borders  of  the  orifice 
incline  towards  the  cervical  ca- 
vity (Figs.  340,  343)  ;  when,  on 
the  contrary,  the  hypertrophy 
has  most  affected  the  internal 
layers  eversion  of  the  lips  takes 
place  (Figs.  341,  343)  and  a 
kind  of  eversion  of  the  os,  which 
spreads  out  like  a  flower,  allow- 
ing the  mucous  membrane  of 
the  cervical  cavity  to  be  seen  on 
the  two  lips,  either  equally  or 
unequally,  according  to  whether 
the  hypertrophy  has  attacked 
these  two  portions  of  the  organ 
equally  or  not.^ 

It  is  to  these  anomalies  of 
form  already  known  that  we 
must  add  that  prolongation  of 
the  cervical  lips  described  by 
Virchow  under  the  name  of 
polypus  of  the  lips  of  the  os.^  I  shall,  however,  have  occasion  to  recur 
again  to  partial  hypertrophy  of  the  segments  of  the  cervix,  which 
deserves  the  serious  attention  of  the  physician  on  account  of  its  con- 
nection with  sterility. 

Diagnosis — subjective  signs. — Patients  often  experience  a  painful 
sensation  of  dragging  in  the  loins,  the  iliac  regions,  even  the  abdomen, 
a  more  painful  sensation  still  of  weight  in  the  pelvis,  produced  by  tension 
of  the  ligaments  and  pressure  of  the  cervix  on  the  rectum,  perinEeum 
and  vulva.  When  standing  they  feel  as  if  the  uterus  were  going  to  escape 
from  the  vulval  opening ;  when  lying  down  they  feel  the  pressure  of 

'  See  the  Atlas  belonging  to  Boivin  and  Duges's  work  and  Huguier's  paper. 
^  Vircliow's  Archiv,  Bd.  ^^i,   S.  164 ;  and   Verliandl.  der  GeseUsch.  f.   Ge- 
bnrtsTc.  Berlin,  Bd   ii,  S.  205,  1847. 


Fig.  343. — Advanced  hypertrophic  elon- 
gation of  the  sub-vaginal  portion, 
affecting  both  lips  equally,  which  di- 
verge in  escaping  from  the  vulva 
(Barnes,  p.  640). 


HYPEETEOPHY   AND    ATEOPHY 


603 


the  organ  to  the  right  or  left  and  a  dragging  when  the  position  is 
changed ;  when  sitting  another  sensation  is  felt,  that  of  compression 


Fig.  344. — Conical  congenital 
hypertrophy,  more  common 
than  the  preceding. 


Fig.  345. — Acquired  hypertrophy,  club-shaped, 
also  more  common  than  the  preceding. 


of  the  tumour  or  of  the  organs  situated  above  it  by  the  chair  on  which 
they  are  seated.  And  if  they  sit  down  quickly  in  a  chair  they  expe- 
rience a  shock  which  is  felt  not  only  in  the  hypertrophied  organ  but  in 
the  abdominal  viscera;  therefore  they  instinctively  sit  down  wdth 
great  care. 

As  for  the  objective  signs  an  idea  will  readily  be  formed  of  the  varie- 
ties of  size  and  form  of  the  organ  by  looking  over  the  different  wood- 
cuts representing  the  various  kinds  of  cervical  hypertrophy.  Bennet  ^ 
gives  a  characteristic  sign  distinguishing  scirrhous  indurations  of  the 
cervix  from  inequalities  due  to  simple  hypertrophic  induration.  When 
division  of  the  cervix  into  knotty  and  irregular  lobes  results  from 
laceration  in  a  previous  confinement  and  is  simply  inflammatory  or 
hypertrophic,  the  fissures  which  separate  the  lobes  radiate  towards  the 
centre  of  the  os,  which  does  not  occur  in  the  case  of  cancerous 
tumour. 

Treatment. — I  have  already  laid  down  the  principal  indications  for 
the  treatment  of  general  hypertrophy  of  the  uterus.  They  are  the 
same  in  hypertrophic  elongation  of  the  cervix ;  effect  depletion  of  the 
organ  when  necessary,  especially  when  there  are  traces  of  inflammation 
or  congestion;  stimulate  absorption  by  resolvents  administered  inter- 
nally and  externally,  by  mercurial  preparations,  iodides,  bromides,  &c., 
and  by  more  general  means  still,  addressed  more  directly  to  the  general 


I  Op.  cit.,  p.  90. 


604 


UTERINE    DISEASES    IN    DETAIL 


niitrition,  such  as  strict  diet  and  regime,  sweating,  hydropathy,  cwa 
famis. 

With  these  general  means  I  combine  energetic  local  treatment,  with 
the  object  of  giving  a  new  direction  to  the  vitality  of  the  organ,  and 
of  bringing  into  action  the  faculty  of  absorption  which  has  been  in 
some  degree  stifled  by  hypertrophy.  The  use  of  these  last  means  is 
doubly  indicated  because  cervical  hypertrophy  is  often  due  to  local 
pathological  conditions  consecutive  to  morbid  states  which,  although 
they  may  have  been  general,  have  yet  only  left  a  limited  result  on  the 
diseased  part.  Sometimes  I  make  more  or  less  deep  scarifications^ 
introducing  into  them  perchloride  of  iron,  or  I  apply  the  actual 
cautery  to  them ;  at  other  times  I  make  ignipunctures  at  the  most 
hypertrophied  points  of  the  organ.  Paquelin's  thermo-cautery  and 
my  small  cauteries  are  the  most  suitable  instruments  for  this  opera- 
tion (pp.  211,  216). 

Unfortunately  medicinal  means  and  the  various  modes  of  cauterisa- 
tion are  insufficient  for  the  treatment  of  serious  hypertrophic  elonga- 
tion. Recourse  must  be  had  to  excision.  Congenital  conoid  hyper- 
trophy does  not  always  necessitate  amputation  of  the  cervix.  Cases 
requiring  incision  must  be  distinguished  from  those  requiring  section. 
Sims  (Kg.  346)  has  represented  very  exactly  a  normal  type  of  rounded 
and  truncated  cervix.  Let  us  suppose  the  cervix  extended  in  the 
direction  of  the  dotted  line  a,  we  shall  then  get  a  very  common  form 
of  conical  cervix  which  is  almost  always  associated  with  constriction  of 
the  OS,  and  almost  as  constantly  with  induration.  Division  of  the  os 
extending  to  the  circular  fibres  will  suffice  to  separate  the  lips,  bring 
the  cervix  back  to  the  form  of  a  rounded  cone,  and  cure  dysmenor- 
rhoea  and  sterility ;  but  if  the  cervix  extends  in  the  direction  of  the 
dotted  line  b,  simple  division  is  not  sufficient.    A  portion  of  the  cervix 


Fig.  346. — Normal  cervix  : 
a,  cervix  slightly  coni- 
cal ;  h,  cervix  very  coni- 
cal (Sims). 


Pig.  347.— Dotted  line 
indicating  the  point 
for  section  of  a  coni- 
cal cervix  (Sims). 


HYPERTROPHY    AND    ATROPHY 


605 


will  require  to  be  amputated,  following  the  transverse  direction  of  the 
dotted  line  in  fig.  347. 

Acquired  hypertrophy,  especially  club-shaped  hypertrophy  (T^igs. 
342,  345)  or  hypertrophy  with  elongation  simulating  procidentia,  is 
not  only  a  cause  of  dysmenorrhoea  and  sterility,  but  it  cannot  be  cured 
by  either  simple  incision  or  by  cauterisation 
applied  in  the  way  I  have  just  described.  When 
hypertrophic  elongation  of  the  cervix  gives  rise 
to  serious  symptoms,  and  has  withstood  the 
means  described,  when  it  is  of  long  standing, 
and  when  it  has  reached  from  5  to  7  centimetres 
in  length,  I  agree  with  Huguier  ^  that  there  is 
only  one  means  of  effectual  cure,  viz.  amputation 
of  the  cervix  \  of  an  inch  from  the  vaginal 
insertion. 

Bennet,^  although  not  in  favour  of  this  ope- 
ration, acknowledges  that  it  should  be  performed 
when  elongation  of  the  cervix  resists  all  means 
of  treatment,  when  it  produces  permanent  dis- 
comfort, and  is  an  obstacle  to  marital  inter- 
course or  a  cause  of  sterility.  West,^  after 
exaggerating  the  dangers  from  haemorrhage  and 
peritonitis,  judging  from  an  unfortunate  case 
performed  by  Paget  with  the  ecraseur,  admits 
that  he  knows  of  no  other  treatment  for  this 
malady  except  ablation  of  the  hypertrophied 
portion.  Scanzoni*  goes  further  in  his  approval 
of  the  operation ;  he  says  :  "I  have  so  often  seen 
the  inefficiency  of  all  therapeutical  means,  local  as 
well  as  general,  that  now  I  always  perform  am- 
putation of  the  cervix."  I  also  have  seen  sterility 
yield  to  amputation  of  the  hypertrophied  cervix. 
This  operation  is  doubly  desirable  when  elonga- 
tion is  complicated  with  a  cyst,  a  fibrous  tumour 
or  epithelioma  commencing  at  the  lower  ex- 
tremity of  the  cervix.  Huguier  says,  "We 
should  have  all  the  less  hesitation  in  performing 
it  in  that  it  is  an  operation  at  once  quick,  easy, 
almost  painless  and  generally  unattended  with 
danger,^  and  that  it  relieves  patients  so  quickly 


Fig.  348.  —  Museux's 
forceps  for  seizing  the 
hypertrophied  cervix : 
A,  with  two  hooks  ;  B, 
with  three  hooks. 


and  surely  of  their  malady."  I  agree  with  this 
opinion  all  the  more  willingly  that  I  know  of  no 
other  means  that  can  be  substituted  for  ablation 
of  the  cervix,  and  that  there  are  cases  in  which 
the  malady  not  only  proves  uncomfortable  but 

'  Op.  cit.,  p.  23. 

■^  Op.  cit.,  pp.  11,  324. 

3  Op.  cit.,  p.  100. 

''  Lchrhucli  der  Kranlilieiten  der  Weiblichcn  Sexnalorgane.     Wicn.  S.  76. 

^  This  operation  however,  like  simple  cauterisation,  is  not  without  danger 


606 


UJEEINE   DISEASES    IN    DETAIL 


painful,  reacting  on  the  whole  economy  and  necessitating  prompt  and 
decisive  intervention.  The  patient  should  lie  on  her  back  so  that 
plenty  of  light  is  thrown  on  the  pelvis.  Sometimes  the  cervix  pro- 
jects at  the  vulva,  in  which  case  the  labia  and  vaginal  walls  may  be 
separated  with  dilators  or  the  fingers  of  an  assistant,  to  reach  the 
point  at  which  the  amputation  is  to  be  performed.  Sometimes  it  is 
hidden  in  the  pelvic  cavity  :  in  which  case  it  must  be  brought  to  view 
by  means  of  a  large  bivalve  speculum,  or  two  dilators.  In  any  case, 
it  is  best  to  follow  Huguier's  advice  to  amputate  the  cervix  without 
using  efforts  to  try  to  bring  it  to  the  vulva  and  without  dragging  on 
the  uterine  ligaments. 

The  cervix  is  then  seized  with  a  strong  tenaculum  hook  or  with 
Museux's  forceps.  It  is  at  first  drawn  upwards,  and  then  with  a  long- 
handled  curved  bistoury  a  semicircular  incision  is  made  at  its  lower 
portion,  half  a  centimetre  below  the  vaginal  insertion.  It  is  then 
drawn  downwards,  and  the  upper  half  of  it  is  divided  in  the  same 


Fig.  349. 


-Amputation  o£    the  vaginal  portion  of    the  hypeiirophied  cervix 
with  Chassaignac's  linear  ecraseur. 


manner.  The  hardness  of  the  tissue  and  the  difficulty  of  managing  the 
bistoury,  sometimes  make  long  curved  scissors  preferable.  I  have 
often  used  them  if  not  to  commence  with,  at  least  to  finish  the  section, 
so  as  to  give  it  the  proper  regularity.  In  fact  I  prefer  using  the 
thermo-cautery  or  a  small  cautery  at  red-heat,  to  avoid  hsemorrhage  in 

Apart  from  opening  the  peritoneum,  examples  of  which  I  shall  give  later  on,  I 
may  just  refer  to  the  case  published  by  Greenhalgh  of  ablation  of  the  cervix 
by  the  ecraseur,  followed  by  peritonitis  and  death  {Obstetrical  Transactions, 
vol.  V,  pp.  75  and  102).  We  should  therefore  be  sure  that  there  is  no  inflam- 
mation of  the  annexes  or  pelvic  peritoneum. 


HYPEETROPHY  AND  ATROPHY  607 

forming  the  posterior  and  anterior  flaps.  Even  when  the  haemor- 
rhage does  not  seem  alarming  at  first  we  should  pay  attention  to  it, 
and  not  leave  the  patient  till  it  has  entirely  ceased.  Plugging  the 
vagina  is  sufficient,  but  it  should  be  done  methodically  :  after  having 
washed  the  cervix  with  cold  vinegar  and  water  or  with  iced  water 
(provided  that  ice  can  be  continuously  applied  for  several  days  to  the 
hypogastrium,  rectum  or  vagina),  small  tampons  of  cotton- wool 
powdered  with  alum  or  saturated  with  tincture  of  perchloride  of  iron 
should  be  laid  against  the  bleeding  surface,  then  compressed  and  kept 
in  place  with  a  number  of  other  tampons  till  the  whole  vaginal  cavity 
is  filled,  when  if  necessary  they  can  be  retained  by  a  T  bandage. 
This  dressing  is  removed  the  next  day  or  the  day  following,  care  being 
taken  to  remove  only  the  superficial  tampons  at  first,  leaving  those 
that  are  in  contact  with  the  amputated  portion  for  some  time  longer, 
and  facilitating  their  removal  by  making  injections  to  prevent  any 
laceration  which  would  inevitably  cause  a  return  of  the  hsemorrhage. 
All  these  inconveniences,  however,  are  avoided  by  the  use  of  the  actual 
cautery. 

When  the  base  of  the  tumour  is  large  and  traversed  by  arteries  the 
pulsations  of  which  can  be  felt,  when  the  patient  is  chlorotic  and  can- 
not be  exposed  without  danger  to  haemorrhage,  the  ecraseur  should  be 
used.  This  instrument,  however,  has  two  disadvantages  :  the  first  is, 
that  it  makes  the  operation  not  only  long  but  painful  when  chloroform 
is  not  used,  on  account  of  the  symptoms  of  strangulation  determined 
by  the  constriction  of  the  chain ;  the  second  is  the  difficulty  of  placing 
the  ecraseur  properly  on  the  cervix  alone  without  including  a  portion 
of  the  vaginal  walls,  and  even  without  touching  the  bladder  or  without 
opening  the  peritoneum.  Huguier  mentions  a  case  that  occurred  in 
LangenbecFs  clinique,  in  which  these  two  accidents  both  happened ; 
the  patient  died  the  third  day ;  a  perforation  of  the  bladder  and  peri- 
toneum was  discovered.^  Therefore  I  have  replaced  the  ecraseur  by 
the  elastic  ligature,  which  has  all  the  advantages  of  the  extemporaneous 
ligature  and  is  more  conveniently  applied.  If  it  is  desirable  to  operate 
more  quickly  the  galvano-canstic  wire  may  be  applied,  which  was  used 
so  successfully  by  Lehmann  [Nederl.  Tidjschrift  voor  Geneesk.,  1877, 
No.  7)  in  a  case  of  prolapsus  with  elongation,  in  which  the  total 
length  of  the  uterus  was  16  centimetres;  but  Paquelin^s  thermo- 
cautery is  better.  We  must  take  precautions  against  consecutive 
obliteration.  I  have  collected  six  cases.  In  order  to  prevent  it  I 
commence  by  dissecting  (with  the  cautery)  two  large  flaps  of  mucous 
membrane,  either  antero-posterior  or  lateral,  and  apply  the  clastic 
ligature  to  the  tissue  proper  at  the  base,  where  the  flap  is  adherent,  or 
I  finish  this  section  with  Paquelin's  thermo-cautery.  The  flaps  of 
mucous  membrane  are  then  united  to  the  tissue  by  a  metallic  suture,  and 

^  This  accident  has  occmTed  several  times,  after  removal  of  the  cervix  by 
the  linear  ecrascvir,  eitlier  on  account  of  hypertrophy  or  cancer.  Besides  Lan- 
genheck's  patient,  in  whom  the  peritoneum  was  injured,  according  to  the  report 
made  by  Mayer  to  the  Obstetrical  Society  of  Berlin,  five  cases  at  least  of  this 
serious  accident  arc  recorded. 


608 


UTERINE    DISEASES    IN    DETAIL 


are  sufficient  afterwards  to  procure  autoplastic  restoration  of  the  orifice. 
This  is,  I  consider,  at  present  the  best  method  of  performing  partial 
section  of  the  cervix. 

When  there  is  no  danger  of  haemorrhage  and  no  special  indication 
for  the  use  of  the  ecraseur,  the  thermo-cautery  or  the  elastic  ligature, 
it  is  better  to  make  a  clean,  transverse  section  of  the  cervix  which 
allows  of  union  by  first  intention.  It  is  to  Marion  Sims  that  we  owe 
this  idea.  In  1859  this  surgeon,  being  about  to  perform  section  of  a 
hypertrophied  cervix,  and  not  having  an  ecraseur  by  him,  slit  the  organ 
on  both  sides  with  scissors  as  far  as  the  insertion  of  the  vagina,  excised 
both  halves,^  and  covered  the  bleeding  surface  with  the  vaginal  mucous 
membrane,  as  the  stump  of  a  leg  is  covered  with  the  skin  after  circular 
amputation.  The  borders  of  the  wound  were  united  from  before 
backwards  with  four  metallic  sutures,  two  on  each  side  of  the  cervical 
canal.  The  wound  healed  by  first  intention ;  the  sutures  were  removed 
nine  or  ten  days  afterwards.  There  was  no  other  opening  than  the 
oval  orifice  of  the  cervical  canal  in  the  centre  of  the  line  of  union. 
Since  then  Sims  has  adopted  this  method  in  his  practice.^  I  have 
also  employed  it  with  success;  but  I  prefer  autoplasty  of  the  cervix  by 
excision  of  two  portions  of  the  uterine  tissue,  after  previous  dissection 


Tig.  350. — Amputation  of  the  cer- 
vix, four  metallic  threads  passed 
though  the  lips  of  the  wound. 


Fig.  351. — Twisted  sutures,  union  by 
first  intention  (Sims). 


of  two  flaps  either  antero-posterior  or  lateral  according  to  my  method, 
or  semicircular  to  allow  of  excision  of  a  conical  portion  of  the  tissue, 
according  to  Max  Markwald^s  method. 

'  Later  on,  he  adopted  a  kind  of  small  guillotine  for  excision  of  the  cervix 
(op.  cit.,  pp.  211,  224). 

■^  Spiegelberg  has  published  a  paper  in  AreMv  filr  GynaeJeol.,  Bd.  v.  Heft  3. 
Berlin,  1873  {Ueber  die  Amputation  des  Scheidentheils  der  Gebdrmutter), 
containing  unpublished  cases  on  various  modes  o£  amputating  the  cervix  in 
cases  of  carcinoma,  hypertrophy,  elongation,  &c.  The  author  prefers  the 
method  of  Sims  for  hypertrophic  elongation  (Hayem,  Revue  des  sciences  medi- 
cales,  iii,  205). 


HYPERTROPHY    AND    ATROPHY  609 

After  amputation  of  the  cervix,  whether  simple  or  by  the  method  of 
Sims,  even  when  followed  by  immediate  union,  if  there  is  consecutive 
contraction  of  the  external  orifice  it  is  better  to  let  things  take  their 
course  than  prevent  union  of  the  wound  by  premature  and  inopportune 
dilatations.  Two  or  three  months  afterwards  the  orifice  can  be  enlarged 
by  incision  and  dilatation,  as  in  cases  of  congenital  narrowness  in  which 
autoplasty  is  practised. 

2.  Supra-vaginal  Hypertrophy  of  the  Cervix 
Hypertrophic  elongation  of  the  supra-vaginal  portion  of  the  cervix 
(cervico- uterine  elongation)  was  discovered  by  Huguier^  in  1849. 
Before  the  appearance  of  his  work  this  elongation  had  been  mistaken 
for  procidentia,  and  although  measurements  had  been  taken  both  on 
the  living  and  dead  body  by  Saviard,  Morgagni,  Hoin,  Levret,  Dance, 
Cloquet  and  Cruveilhier,  which  proved  excessive  length  of  the  supra- 
vaginal portion  of  the  cervix  and  the  presence  in  the  pelvis  of  the 
supposed  prolapsed  uterus,  no  conclusions  had  been  drawn  from  them 
as  to  the  existence  of  cervico-uterine  hypertrophy,  its  diagnosis  or 
treatment. 

West^  refers  in  a  few  words  to  the  existence  of  supra- vaginal  hyper- 
trophy. He  mentions  the  case  quoted  by  Morgagni^  and  the  descrip- 
tion given  of  it  by  some  German  writers,  especially  by  Virchow,^  under 
the  name  oi  prolapsus  of  the  womb  without  descent  of  the  fundus.  He 
mentions  a  specimen  of  this  kind  of  alteration  which  is  in  the  Museum 
of  St.  Bartholomew's  Hospital,  series  xxxii,  30.  He  justly  remarks 
that  the  mechanical  means  of  support  and  reduction,  which  are  useful 
in  true  prolapsus,  are  useless  here  and  only  aggravate  the  sufferings 
of  the  patient. 

Diagnosis — subjective  signs.  —  The  principal  are  the  following  : 
abnormal  heat  and  sensibility,  pain,  muco-purulent  hypersecretion 
from  the  uterus.  Menstruation  usually  longer  and  more  abundant, 
prolonged  after  the  age  of  the  menopause,  sometimes  accompanied  by 
metrorrhagia.  Marital  intercourse  often  difficult  or  impossible,  and 
generally  sterility.  Micturition  frequent,  painful,  difficult  and  even 
impossible,  unless  the  patient  pushes  the  tumour  backwards  and  up- 
wards with  her  hand ;  for  the  bladder  partly  escapes  from  abdominal 
pressure,  its  walls  are  relaxed  and  weakened,  and  the  urethra  is  strongly 
flexed  at  the  point  where  it  crosses  the  subpubic  ligament  and  Wilson's 
muscle.  Sometimes  there  is  incontinence  of  urine,  at  other  times  re- 
tention. The  clothes,  the  abdomen  and  the  tumour  are  soiled  by  con- 
tact with  the  urine,  which  cannot  be  voided  in  a  jet ;  hence  itching, 
irritation,  frequently  even  excoriation  and  ulceration  of  the  vaginal 
mucous  membrane,  especially  of  that  which  covers  the  anterior  surface 
1  Memoire  sur  les  allongements  hypertrophiques  dii  col  de  I'uterus  dans  les 
affections  designees  sous  le  nom  de  descente,  de  precipitation  de  cet  organe,  et 
sur  leur  traitement  par  la  resection  ou  V amputation  de  la  totalite  du  col, 
suivant  la  variete  de  la  maladie.  Paris,  1860. 
^  Op.  cit.,  pp.  144-45. 

^  Morgagni,  De  sedibus  et  Causis  Morborum,  folio.  Venetiis,  1761,  2nd  vol., 
epist.  45,  art.  11,  p.  204. 

''  Verhandl.  der  Gesellschaft  f.  GeburtsJmlfe  in  Berlin,  vol.  ii,  p.  205, 1847. 

•^9 


610 


UTERINE   DISEASES    IN    DETAIL 


of  the  tumour.  There  is  constipation  and  difficulty  of  defecation  from  the 
retention  of  fsecal  matters  at  the  point  where  the  tumour  projects  into 
the  rectum,  patients  being  sometimes  obliged  to  lift  the  tumour  upwards 
and  forwards,  to  favour  the  accomplishment  of  this  act.     When  the 


Fig.  352. —  Considerable  hypertropliic  elongation  of  the  supra- vaginal  portion 
especially,  but  also  of  the  sub-vaginal  portion.  From  a  preparation  in  St. 
Bartholomew's  Museum.  The  Fallopian  tubes  are  also  diseased.  The 
vagina  contains  the  globular  portion  of  the  elongated  cervix  (Barnes). 

perinseum  is  lacerated  there  is  at  the  same  time  incontinence  of  faecal 
matter ;  in  such  cases  there  is  irritation  and  frequently  ulceration  of 
the  posterior  half  of  the  tumour. 

Lastly,  when  the  patient  is  obliged  to  walk  or  work,  in  addition  to 
the  general  feeling  of  discomfort,  there  is  a  dread  of  the  viscera 
escaping  through  the  vulva,  there  being  no  longer  any  resistance  from 


HYPERTROPHY    AND   ATROPHY 


611 


the  perinseum,  and  she  also  experiences  constant  pain,  dragging  in  the 
lumbo-sacral  region,  sometimes  in  the  hypogastrium  and  groins,  at  other 


Fig.  353. — Hypertrophic  elongation,  principally  of  the  supra-vaginal  portion 
of  the  neck,  simulating  prolapsus  :  /,  fundus  ;  i,  isthmus  ;  c,  cervix  (from 
nature,  after  Farre). 

times  in  the  epigastrium.     Every  position,  especially  the  vertical  one, 
becomes  difficult.     Lastly,  digestion  and  nutrition  are  disturbed. 

Objective  sights. — In  procidentia  the  sound  penetrates  to  a  depth  of 
from  6  to  7  centimetres,  in  elongation  from  9  to  15  centimetres  and 
exceptionally  to  20.     The  sound  also  allows  us  to  ascertain  the  direc- 
tion of  the  cervico-uterine  canal,  the   situation  of  the  fundus,  &c. 
Other  means  also  allow  a  differential  diagnosis  to  be  established  and 
completed  by  the  discovery  of  other  elements  which  may  exist  in  the 
tumour.     For  instance,  in  hypertrophic  elongation,  rectal  touch  dis- 
covers the  cervix  and  above  that  the  body  of  the  uterus  ;  in  procidentia 
it  reveals  a  vacuum  in  the  middle,  and  laterally  two  painful  cords,  ex- 
tending from  the  angles  of  the  womb  and  formed  by  the  round  liga- 
ments, the  ovaries  and  the  Pallopian  tubes.     A  sound  passed  into  the 
bladder  and  directed  towards  the  rectum  is  arrested  in  the  middle  by 
the  hypertrophied  cervix  ;  on  the  contrary  it  may  be  felt  by  the  finger 
placed  in  the  rectum  above  and  behind  the  uterus  when  the  latter  is 
merely  prolapsed.     Palpation   of  the  tumour  in  cases  of  elongation 
discovers  the  presence  in  its  centre  and  throughout  its  whole  length  of 
a  hard  and  rather  broad   cylinder ;  while  in  procidentia  it  reveals  a 
vacuum  in  the  centre  of  its  base,  and  below  this  a  firm  elastic  body, 
of  the  form  and  consistency  of  the  uterus,  and  continuous  with  the  sub- 
vaginal  portion  of  the  cervix,   which  is    visible  externally.     Lastly, 
attempted  reduction  of  the  tumour  gives  quite  different  results  in  both 
cases :  in  procidentia,  the  first  part  of  reduction,  that  of  making  the 
body  of  the  uterus  pass  through  the  vulva,  may  be  painful,  difficult  or 


612 


UTEEINE    DISEASES    IN    DETAIL 


impossible,  especially  during  the  menstrual  period ;  the  second  part  is 
easy,  the  parts  seeming  to  go  up  of  themselves,  the  patient  is  soothed 
and  the  uterus  may  be  maintained  by  a   pessary  ;  in  hypertrophic 


Pig.  354. —  Complete  procidentia,  from  a  preparation  in  St.  George's  Museum 
(Barnes),  pa,  anterior  peritoneal  fossa;  pp,  posterior  peritoneal  fossa; 
T,  cystocele  ;  E,  rectum  ;  p,  pubis  ;  u,  urethra ;  A,  anus  ;  o,  ovaiy  ;  v, 
bladder ;  M,  womb. 

elongation  reduction  is  easy  at  any  time,  either  before  or  after  men- 
struation, the  entrance  of  the  tumour  is  effected  without  any  resist- 
ance from  the  vulval  orifice,  it  takes  place  gradually,  without  pain  till 
the  cervix  is  on  a  level  with  the  lower  extremity  of  the  vagina ;  flat, 
oval,  annular  pessaries  may  then  be  borne  with  benefit ;  but  if  we  wish 
to  raise  this  part  higher,  to  its  normal  position,  we  usually  feel  resist- 
ance, the  uterus  becomes  curved  on  itself,  and  more  or  less  acute  pain 
is  produced,  or  the  body  of  the  uterus  is  raised  out  of  the  pelvic  into 
the  abdominal  cavity,  where  it  causes  great  discomfort  and  even  un 
bearable  pain  by  its  pressure  on  the  neighbouring  parts  and  by  the 
tension  exercised  on  its  own  ligaments.  These  considerations  are  very 
useful  in  establishing  a  differential  diagnosis. 

Treatment. — The  impossibility  of  reducing  the  tumour  and  of  main- 
taining it  reduced  in  confirmed  hypertrophic  elongation  explains  how 
this  malady,  reputed  to  be  incurable,  becomes  a  real  infirmity  which 
only  rest  combined  with  the  use  of  vulval  bandages  of  various  kinds 


HYPERTROPHY    AND    ATROPHY  613 

makes  bearable.  The  discomfort  attendant  on  micturition  of  which  I 
have  spoken,  the  contact  of  the  urine  with  the  tumour,  the  friction  of 
the  latter  against  the  clothes,  and  the  ulceration  which  follows  cause 
such  constant  discomfort  that  the  intervention  of  art  becomes  neces- 
sary. Unfortunatelj  the  means  at  our  disposal  are  very  incomplete, 
and  are  only  successful  when  the  malady  is  slight. 

As  for  medical  means,  those  which  I  have  enumerated  in  speaking 
of  general  hypertrophy  may  be  used ;  the  horizontal  posture  with  the 
pelvis  raised,  iodide  of  potassium,  ergot,  cold  enemata,  frictions  with 
resolvent  ointment,  &c. 

When  the  elongation  is  not  very  extensive  (about  2  or  3  centi- 
metres), when  the  upper  extremity  of  the  vagina  only  is  inverted  and 
when  the  whole  of  the  tumour  does  not  protrude  more  than  from  4  to 
5  centimetres  beyond  the  vulva  when  the  patient  strains  in  a  standing 
position,  the  cervix  and  vagina  can  usually  be  kept  reduced  by  one 
of  the  numerous  varieties  of  pessaries  (especially  Hodge^s  lever 
pessary).  Unfortunately  reduction  cannot  always  be  maintained  for 
want  of  apoini  d'appui  owing  to  the  considerable  enlargement  of  the 
transverse  diameter  of  the  vaginal  opening.  Their  diameter  must 
therefore  be  proportioned  to  that  of  the  vaginal  opening.  I  know  a 
woman  aged  sixty  affected  with  hypertrophic  elongation  measuring 
nearly  12  centimetres,  mistaken  till  lately  for  a  simple  prolapsus ;  she 
was  accustomed  to  reduce  it  by  means  of  a  large  ball  of  linen  which 
served  as  a  pessary,  and  although  suffering  discomfort  she  is  able  to 
do  a  great  deal  of  hard  work  in  a  maternity  hospital.  When  the  pro- 
lapsed parts  can  be  raised  above  the  vulval  opening  and  when  patients 
cannot  tolerate  any  kind  of  pessary,  we  must  be  content  with  main- 
taining the  tumour  in  this  position  by  means  of  an  oval  plate  sup- 
ported by  elastic  bands,  or  mounted  on  a  steel  spring  fixed  to  a  belt. 
Unfortunately  the  presence  and  pressure  of  this  plate  can  hardly  be 
borne  by  women  who  have  hard  work  to  do ;  sometimes  too  the  uterus 
escapes  at  one  side  of  the  instrument,  and  the  contact  of  the  latter 
irritates  the  organs  and  provokes  secretions  so  that  patients  are 
obliged  to  lay  it  aside. 

When  these  means  are  found  insufficient,  an  operation  should  be 
tried.^  This  operation,  which  consists  in  removing  a  part  or  the 
whole  of  the  cervix  with  the  upper  extremity  of  the  vagina,  by  scoop- 
ing it  out  from  without  inwards,  after  having  previously  detached  the 
bladder  from  the  part  which  is  to  be  removed,  has  been  suggested  by 
Huguier  under  the  name  of  conoid  amputation  of  the  cervix.  It  has 
been  successfully  performed  by  this  surgeon  and  by  others  ;  I  have 
performed  it  several  times  with  equal  success ;  and  although  not 
exempt  from  danger,  it  seems  to  me  that  it  ought  to  be  accejjted  as 
the  only  means  of  curing  an  infirmity  which  though  not  endangering 
life    yet  produces  very  great    discomfort.     We  must   not,  however, 

^  I  ao;ree  with  Marion  Sims  who,  while  approving  of  Huguier's  operation, 
says,  that  as  a  rule  conoid  amputation  should  only  be  made  when  there  is 
hypertrophic  elongation  of  the  infra- vaginal  portion  of  the  cervix  as  well  a& 
procidentia  and  supra-vaginal  hypertrophy. 


61*4  UTERINE   DISEASES    IN    DETAIL 

forget  that  the  most  serious  accidents  may  be  developed,  for  they 
occur  on  the  occasion  of  much  less  serious  operations.  Metritis  or 
peritonitis  may  cause  the  death  of  patients.  Peter/  the  translator  of 
the  last  edition  of  Bennet's  Treatise  on  Uterine  Inflammation,  mentions 
an  unfortunate  case  of  the  kind  which  he  saw.  The  surgeon  must 
judge  of  each  case  individually,  taking  into  account  all  the  indications 
and  contra-indications. 

The  object  of  the  operation  is  not  merely  to  amputate  the  sub- 
vaginal  portion  of  the  cervix,  but  also   to   remove   that   extending 
between  the  insertions  of  the  vagina  and  the  body  of  the  organ,  which 
is  the  principal  seat  of  hypertrophy.     It  should  be  performed  a  few 
days  after  the  menstrual  period,  the  patient  having  since  then  made 
very  hot  injections  and  kept  the  horizontal  posture.     The  first  part  of 
the  operation  consists  in  section  of  the  posterior  walls  of  the  vagina 
and  cervix.     The  danger  incurred  is  that  of  lesion  of  the  peritoneum. 
To  avoid  it  the  surgeon  introduces  the  index  finger  of  the  left  hand 
into  the  rectum,  pressing  against  the  anterior  wall  of  the  intestine ; 
this  finger  indicates  to  the  eye  the  limit  of  the  recto-vaginal  fold  of  the 
peritoneum,  and  serves  as  a  guide  during  the  whole  operation.     The 
portion  of  the  vagina  which  is  inserted  on  the  cervix  is  incised  above 
this  finger,  whilst  an  assistant  pushes  the  whole  tumour  upwards  and 
forwards  by  means  of  a  pair  of  Museux's  forceps  fixed  in  the  posterior 
lip  of  the  cervix.     This  incision  is  carried  at  first  towards  the  cervical 
cavity  to  avoid  the  peritoneum,  then  into  the  uterine  tissue  obliquely, 
from  below  upwards,  and  from  without  inwards  till  the  cervical  cavity 
is  reached.    The  second  part  of  the  operation  consists  in  section  of  the 
anterior  walls  of  the  vagina  and  cervix.     The  chief  danger  incurred  is 
injury  to  the  bladder.     To  avoid  it,  a  sound  is  introduced  into  this 
organ  and  directed  downwards  into  the  lower  portion  of  the  vesical 
cicl  de- sac  "^hich  invariably  forms  the  anterior  part  of  the  tumour; 
this  part  is  raised  and  rendered  prominent,  and  the  assistant  to  whom 
the  sound  is  entrusted  is  told  to  make  it  perceptible  to  both  finger  and 
eye.     The  anterior  lip  of  the  cervix  is  seized  with  Museux^s  forceps 
and  drawn  down  by  an  assistant ;  the  surgeon  then  makes  a  horizon- 
tal  and   semi-lunar  incision,  convex  above,  at   about  one  centimetre 
from  the  projection  formed  by  the  sound,  which  embraces  the  anterior 
portion  of  the  cervix,  its  extremities  joining  those  of  the  first  incision. 
The  anterior  surface  of  the  cervix  below  the  bladder  must  only  be 
reached  by  small  incisions;  when  the  operation  has  arrived  at  this 
point  the  sound  is  taken  away ;  the  bladder  is  separated  by  a  careful 
dissection  from  the  anterior  portion  of  the  cervix  to  an  extent  of  from 
2  to  4  centimetres  in  the  centre,  and  from  40  to  50  millimetres  on 
the  sides,  for  fear  of  injuring  the  ureters;  after  which  the  anterior 
wall  is  divided  from  the  cervix  obliquely  from  below  upwards  and 
from  before  backwards^  till  the  cervical  cavity  has  been  reached,  as 
has  been  done  for  the  posterior  wall.     The  portion  taken  from  the 
uterus  ought  to  be  cone-shaped,  the  base  corresponding   with   the 
cervix,  and  the  vagino-uterine  wound  funnel-shaped,  the  most  con- 

1  Op.  cit.,  p.  463. 


HYPERTROPHY    AND    ATROPHY  615 

tracted  portion  corresponding  to  the  uterine  cavity.  In  order  to  pre- 
vent hsemorrhage;  especially  after  the  operation,  the  arteries  should  be 
ligatured  as  they  are  opened.  The  uterine  tissue  is  so  dense  and 
friable  that  it  is  very  difficult  for  the  ligatures  to  keep  a  hold  of  them. 
Huguier  has  invented  an  ingenious  method  of  ensuring  constriction  : 
the  use  of  hooked  pins.  In  place  of  seizing  the  uterus  with  forceps 
or  with  an  ordinary  tenaculum  hook,  he  uses  a  good  strong  pin  in  the 
form  of  a  fish-hook  to  the  head  of  which  a  long  thread  is  attached.  A 
ligature  is  made  on  the  parts  fixed  by  the  pin,  the  point  of  -which  is 
cut  at  1  millimetre  from  the  knot,  so  as  to  prevent  it  from  pricking 
and  hurting  the  neighbouring  parts.  The  whole  is  left  in  place  and 
falls  from  the  third  to  the  fifth  day.  In  applying  the  ligatures  in  this 
way  as  the  arteries  are  opened  time  is  gained,  the  loss  of  a  quantity  of 
blood  is  avoided,  and  the  patient  spared  a  subsequent  hsemorrhage. 
When  hsemorrhage  continues  in  spite  of  the  use  of  the  ecraseur  and  in 
spite  of  the  appHcation  of  tenaculum  ligatures,  the  vagina  must  be 
plugged  as  after  amputation  of  the  subvaginal  portion  of  the  cervix. 
I  have  left  this  description  unaltered  because  there  are  cases  in  which 
it  is  necessary  to  have  recourse  to  the  bistoury  in  order  to  avoid  the 
formation  of  cicatricial  tissue  and  preserve  the  flexibility  and  supple- 
ness of  the  uterus,  but  I  should  add  that  latterly  when  performing  this 
operation,  especially  in  old  women,  I  have  used  very  small  cauteries  or 
Paquehn's  thermo-cautery  in  place  of  the  bistoury.  I  have  also  pre- 
scribed very  hot  injections  previously  as  a  preventive  haemostatic  means, 
and  I  think  the  gravity  of  the  operation  is  greatly  diminished  by  their 
use.  After  section  of  the  cervix  has  been  performed,  I  push  the  rest 
of  the  uterus  and  vagina  back  into  the  pelvis,  and  make  no  other 
ap])lication  than  simple  detersive  vaginal  injections.  Cicatrisation  is 
usually  completed  towards  the  twentieth  day.  The  upper  extremity  of 
the  vagina  is  then  retracted  and  punctured;  it  presents  a  reddish 
cicatrix  nearly  2  centimetres  long,  at  the  base  of  which  is  felt  a  small 
mammillated  eminence  the  size  of  a  finger-tip,  pierced  in  the  centre  by 
a  small  transverse  opening :  it  is  the  lower  part  of  the  uterus.  The 
womb  at  the  end  of  two  or  three  months  is  less  voluminous  and  shorter 
than  after  the  operation:  it  diminishes  from  1  to  1|  centimetres. 
This  diminution  is  to  be  attributed  to  the  resolution  and  suppuration 
which  have  followed  the  solution  of  continuity,  as  well  as  to  the 
retraction  of  the  cicatrix.  The  procidentia  is  then  radically  cured, 
except  in  cases  in  which  there  is  a  very  wide  pelvis  and  vulval  open- 
ing, a  more  or  less  lacerated  perinsaum,  and  considerable  weakening  of 
all  the  soft  parts  which  form  the  floor  of  the  pelvis,  and  when  the 
body  of  the  uterus  is  completely  prolapsed  from  the  pelvis  and  in 
retroflexion,  so  that  the  fundus  of  the  organ  is  lower  than  the  cervix. 
These  various  circumstances  contra-indicate  operation,  or  at  least  give 
no  hope  for  complete  success. 

Lastly,  when  the  malady  is  preceded  by  a  voluminous  rectocele  or 
cystocele,  or  by  both,  it  may  be  necessary,  after  removal  of  the  cervix, 
to  operate  for  the  herniffi  of  the  rectum  and  bladder  separately.  The 
best  way  of  operating  consists  in  destroying  on  each  side  a  circular 


616  UTERINE    DISEASES  IN    DETAIL 

portion  of  the  vaginal  wall  which  covers  them^  in  order  to  determine 
strong  cicatricial  retraction.  It  is  important  in  dissecting  the  vaginal 
wall  to  avoid  injuring  the  bladder  and  rectum.  Huguier  has  con- 
trived for  this  end  an  ingenious  method,  which  he  applies  one  or  two 
months  after  conoid  section  of  the  cervix,  i.  e.  when  the  first  wound  is 
cicatrised,  the  patient  out  of  bed,  and  the  result  of  the  operation  can  be 
judged  of.  Por  cystocele,  after  having  previously  dilated  the  urethra 
with  prepared  sponge,  he  introduces  the  little  finger  by  this  canal,  and 
if  possible,  the  index  finger  of  the  left  hand  into  the  bladder.  He 
seizes  the  tubercle  and  the  anterior  wall  of  the  vagina  with  a  small 
pair  of  Museux^s  forceps,  making  an  assistant  draw  them  downwards 
and  forwards,  so  as  to  stretch  them  and  separate  them,  if  possible, 
from  the  corresponding  wall  of  the  bladder.  Then  he  passes,  at  the 
base  of  the  fold  formed  by  the  part  of  the  vaginal  wall  which  he  wishes 
to  remove,  a  long  pin,  or  several  pins  crossed,  for  example  four,  form- 
ing two  crosses,  taking  care  that  the  pins  traverse  the  cellular  tissue 
lying  between  the  vagina  and  bladder  without  touching  the  walls  of 
this  organ,  of  which  he  is  warned  by  the  finger  introduced  into  the 
vesical  cavity.  He  throws  a  loop  of  thread  behind  each  cross  formed 
by  the  pins,  forms  a  pedicle  of  the  whole  with  a  triple  thread  and 
applies  the  ecraseur.  The  same  operation  may  be  performed  simulta- 
neously on  the  posterior  wall  of  the  vagina  covering  the  rectum,  care 
being  taken  to  introduce  the  index  finger  into  the  intestine  to  serve  as 
a  guide,  and  to  preserve  the  wall  of  the  organ,  remembering  that  the 
upper  portion  of  the  rectocele  is  not  only  in  proximity  to  the  anterior 
wall  of  the  rectum,  but  also  with  the  vagino-rectal  cul-de-sac  of  the 
peritoneum. 

3.  Hypertrophy  of  the  Cervix  limited  to  one  Segment  or  to  one  Lip} 
I  have  already  said  (p.  602)  that  the  two  lips  of  the  cervix  may  be 

*  I  cannot  better  sum  up  my  opinion  on  partial  hypertrophy  of  the  cervix 
than  by  quoting  the  conclusions  of  the  paper  on  this  subject  presented  to  the 
Academy  of  Medicine,  22  May,  1877. 

1.  Partial  hypertrophy  of  the  cervix  is  an  increase  of  volume  limited  to  one 
point  of  this  organ. 

2.  It  must  not  be  confounded  with  tumours  properly  so-called  of  this  organ. 

3.  It  exists  in  the  peripheric  parts  or  in  the  parts  which  form  the  walls  of 
the  cervical  cavity. 

4.  This  partial  hypertrophy  of  the  walls  of  the  cervical  cavity  is  the  least 
known  and  the  most  important  to  recognise. 

5.  It  exists  most  frequently  in  the  median  line.  It  is  often  congenital, 
depending  on  arrested  absorption  of  the  partition  which  separates  primitively 
the  two  uteri,  and  of  which  the  columns  of  the  arbor  viteg  are  the  vestiges. 

6.  The  irritation  caused  by  excessive  coitus  and  inflammation  of  the  cervix 
after  abortion  or  delivery,  also  cause  or  increase  it. 

7.  It  is  often  situated  on  a  level  with  the  vaginal  orifice,  lies  frequently  on 
a  level  with  the  isthmus,  more  rarely  in  the  central  portion. 

8.  The  subjective  signs  are  sometimes  those  of  metritis  or  dysmenorrhcea 
(for  deep-seated  hypertrophy),  always  sterility.  Usually  there  is  the  contrast 
of  persistent  sterility  with  the  absence  of  dysmenorrhoeic  symptoms. 

9.  The  most  marked  objective  sign  is  the  semi-lunar  form  of  the  os ;  in 
hypertrophy  of  the  upper  part  of  the  cervix  there  is  difficulty  in  passing  the 


HYPERTROPHY  AND  ATROPHY  617 

unequally  hypertrophied  so  as  to  place  the  orifice  on  the  one  or  the 
other  surface^  and  even  to  hide  it  behind  the  most  hypertrophied  lip. 
I  have  given  examples  of  sterility  due  to  this  cause^  in  vt^hich  aptitude 
for  conception  has  been  restored  by  the  cure  of  the  hypertrophy  [see 
chapter  on  Sterility).  Here  I  wish  to  give  a  brief  but  more  complete 
explanation  of  the  various  kinds  of  partial  hypertrophy  which  may  aflect 
one  of  the  segments  of  the  cervix. 

In  this  kind  of  partial  hypertrophy  it  is  not  one  of  the  transverse 
segments  of  the  cervix  which  is  affected,  but  one  of  its  two  longitudinal 
segments,  the  anterior  or  the  posterior.  The  anterior  has  seemed  to 
me  more  frequently  affected  than  the  posterior.  I  have  reason  to 
believe  it  is  the  same  with  the  body,  and  that  partial  hypertrophy  may 
exclusively  affect  either  the  anterior  or  posterior  segment,  and,  if  I 
may  judge  by  my  own  observations,  it  is  more  commonly  the  posterior. 
These  partial  hypertrophies  of  the  body,  however,  besides  being  more 
difficult  to  verify  than  those  of  the  cervix,  do  not  produce  such  marked 
symptoms,  and  are  not  so  easily  curable.  Hypertrophy  of  one  of  the 
segments  of  the  cervix  is  often  observed  at  the  lower  part  of  this  organ, 
i.  e.  on  one  of  the  cervical  lips;  but  it  may  exist  also  at  its  upper  ex- 
tremity, as  well  as  at  its  median  part,  and  even  in  its  whole  extent. 

Sometimes  we  can  only  gain  an  exact  idea  of  the  existence  and  seat 
of  this  partial  hypertrophy  after  dilating  the  cervix  with  sponge  tents. 
We  then  see  clearly  that  the  obstacle  to  the  free  penetration  of  the 
sound  is  a  partial  hypertrophy  of  one  lip  (in  this  case  the  anterior  one) 
a  little  above  the  orifice,  and  therefore  we  cauterise  at  the  seat  of  the 
hypertrophy  or  the  cervix  itself,  penetrating,  however,  deeply  into  the 
hypertrophied  lip. 

Hypertrophy  of  one  lip  not  only  is  more  frequently  observed  than 
other  forms  of  hypertrophy,  but  it  is  more  frequent;  for  whilst  some- 
times congenital,  as  the  others  generally  are,  it  is  much  more  commonly 
than  these  the  consequence  of  chronic  congestion  or  inflammation. 
Now  the  causes  of  these  morbid  states  are  much  more  numerous  for 
the  cervico-vaginal  than  for  the  cervico-uterine  portion  of  the  neck, 
more  numerous  also  for  the  anterior  lip  (which  is  more  commonly 
hypertrophied)  than  for  the  posterior.  The  hypertrophied  lip  may 
assume  various  forms :  sometimes  it  is  very  voluminous,  especially  ex- 
ternally, entirely  hiding  the  opposite  one  by  projecting  beyond  it; 
sometimes,  on  the  contrary,  it  is  more  developed  internally,  and  then 
it  distends  the  opposite  lip  and  becomes  covered  by  it;^  sometimes  it 

sound ;  dilatation  by  sponge  tents  and  subsequent  use  of  the  sound  allow  of 
its  being  distinguished  from  anteflexion. 

10.  Treatment  consists  in  general  and  local  resolvents  (baths,  injections, 
medicated  pessaries,  hydroi^athy) . 

11.  The  special  means  are  dilatation  by  sponge  tents,  scarifications  or  caus- 
tics for  hypertrophy  situated  at  the  cervico-uterine  isthmus,  ignipuncture  foi* 
hypertrophy  situated  at  the  vaginal  orifice. 

12.  The  cure  of  partial  hypertrophy  of  the  cervix  leads  to  the  cure  of  the 
sterility. 

'  Figs.  355,  356,  give  an  exact  idea  of  this  arrangement.  The  cervix,  as 
seen  through  the  speculum  (Fig.  355),  shows  a  marked  increase  in  the  size  of 
the  anterior  lip.     The  orifice  assumes  the  form  of  a  crescent,  convex  posteriorly, 


618 


UTERINE    DISEASES   IN    DETAIL 


is  broad  and  thin,  exceeding  the  other  lip^  over  which  it  falls  like  an 
apron ;  at  other  times  it  is  narrow  and  long  and_,  projecting  beyond  the 
opposite  lip,  assumes  the  form  of  a  beak  or  snout. ^     Even  when  the 


Fig.  355. 


Fig.  356. 


uterus  is  conical,  and  when  the  os  is  reduced  to  a  pin-point,  not  un- 
frequently  this  pin-point  instead  of  being  at  the  summit  of  the  cone  is 
on  its  posterior  surface,  constituting  true  hypertrophy  of  the  anterior 
lip ;  sometimes  the  hypertrophy  seems  connected  with  flexion  of  the 
cervix,  and  in  this  case  the  lip  corresponding  to  the  convexity  without 
being  thicker  is  much  longer  than  the  other  (anteflexion  being  most 
common,  it  is  the  posterior  lip  which  is  usually  the  seat  of  this  elonga- 
tion, of  this  hypertrophic  extension). 

These  various  kinds  of  hypertrophy  are  met  with  in  women  who  have 
never  conceived,  and  are  either  congenital  (in  which  case  they  chiefly 
affect  the  conical  form)  or  acquired  in  consequence  of  venereal  excesses 
or  local  disease  neglected  for  a  long  time.  They  are  observed  more 
frequently  in  multiparse;  then  they  are  always  acquired,  and  are  due 
to  chronic  inflammation  which  has  hypertrophied  the  organic  tissue  or 
the  mucous  membrane.  They  are  a  common  cause  of  sterility,  though 
not  generally  recognised  as  such,  for  though  presenting  an  obstacle  to 
the  penetration  of  the  semen,  they  permit  the  easy  discharge  of  the 
menses,  and  consequently  do  not  attract  the  attention  of  patients.  I 
have  seen  in  several  sterile  women  a  partial  hypertrophy,  the  remains 
of  the  union  of  the  two  uteri,  more  common  before  than  behind,  and 
exaggerated  by  the  natural  anteflexion  of  the  organ.  This  tubercle, 
which  may  be  called  the  uterine  uvula,  is  similar  as  regards  position 
and  symptomatological  consequences  to  hypertrophy  of  the  median  lobe 
of  the  prostate.     It  does  not  always  prevent  the  escape  of  the  menses, 

sure  sign  of  hypertrophy  of  the  anterior  lip.  The  sound  only  penetrates  into 
the  uterus  by  following  the  curve  formed  by  the  cervical  cavity,  as  is  indicated 
in  the  section  of  the  uterus,  shown  in  Fig.  356.  The  posterior  lip  covers  the 
anterior  lip  partly.  Sims  also  refers  to  this  semi-lunar  form  of  the  orifice 
(op.  cit.,  p.  223). 

1  Beigel  has  made  similar  observations  {Berlin.  Klin.  Wochensch.,  1867, 
Nos.  47,  48). 


HYPERTROPHY    AND    ATROPHY  619 

but  even  when  it  offers  no  obstacle  to  any  discbarge  from  the  interior 
it  opposes  an  impassable  barrier  to  the  entrance  of  any  fluid  from 
without. 

Hypertrophy  of  the  median  portion  of  the  cervix  is  less  frequent 
than  that  of  its  extremities.  In  this  the  cervix  follows  the  law  of  every 
hollow  organ,  the  orifices  of  which  are  the  seat  of  hypertrophy  or  of 
the  development  of  tumours  and  of  degeneration  more  frequently  than 
the  walls.  But  it  exists  all  the  same,  especially  in  the  columns  of  the 
arhor  vitce,  sometimes  on  both  simultaneously,  but  more  commonly  on 
one  only,  the  other  being  depressed  by  the  progressive  development  of 
the  former.  Usually  it  is  consecutive  to  hypertrophy  of  the  internal 
orifice  or  of  the  lips  of  the  vaginal  orifice,  and  gradually  disappears 
towards  the  median  portion  of  the  cervix.  It  may,  however,  be  inde- 
pendent of  it,  existing  alone. 

Diagnosis, — This  is  easily  made  when  we  are  aware  of  the  possi- 
bility of  the  existence  of  such  a  disease.  I  am  sure  that  I  often 
ignored  it  in  the  beginning  of  my  gynaecological  practice.  Besides 
the  subjective  signs,  sterility,  dysmenorrhoea  and  the  other  symptoms 
of  hypertrophy,  sight,  touch,  and  the  sound  especially  leave  no  doubt 
on  the  subject.  Sight  and  touch  only  discover  the  excessive  size  of 
one  of  the  lips,  or  the  alteration  in  the  form  of  the  orifice.  The  in- 
ternal seat  of  the  hypertrophy  of  the  tumefied  lip  is  disclosed  by  the 
sound,  which  alone  permits  of  the  verification  of  partial  hypertrophy 
of  the  median  portion  and  of  the  os  internum. 

Treatment. — I  shall  add  nothing  to  what  I  have  already  said  as  to 
resolvent  treatment,  general  and  local,  solvents,  tampons  of  glycerine, 
and  glycerole  of  iodide  of  potassium,  which  may  be  applied  here  as  in 
other  kinds  of  hypertrophy.  There  are,  however,  two  points  upon 
which  I  ought  to  insist,  because  they  may  lead  to  cure  without  neces- 
sitating recourse  to  operation :  I  refer  to  puncture  with  the  actual 
cautery,  and  the  application  of  dilating  bodies.  It  is  especially  in 
hypertrophy  limited  to  one  of  the  cervical  lips  that  I  have  been  able 
to  observe  the  marked  resolvent  action  of  the  actual  cautery ;  but  it 
is  principally  in  this  case  that  the  tissue  must  be  pierced  with  pointed 
cauteries  at  red  or  white  heat  according  to  the  size  of  the  tumefaction, 
taking  care  to  spare  the  circumference  of  the  orifice ;  although  the 
cautery  may  be  introduced  into  the  cervical  cavity,  this  is  not  usually 
indispensable  (^see  Fig.  194,  p.  213,  representing  ignipuncture  of  the 
hypertrophied  anterior  lip). 

As  for  laminaria  or  sponge  tents,  they  produce  the  most  remarkable 
efi'ects ;  it  is  sometimes  necessary  to  slit  the  cervix  or  to  incise  the 
portion  of  the  prominent  lip  slightly  in  its  thickness,  then  to  dilate  the 
cervix  with  tents  of  increasing  size,  and  lastly  to  profit  by  the  dila- 
tation to  incise,  excise,  or  abrade  the  exuberant  tissues.  But  dilata- 
tion alone  sufiices  to  produce  great  modification  of  the  hypertrophy ; 
it  softens  the  tissue,  determining  hypersecretion,  a  discharge  which 
may  be  increased  by  the  addition  of  a  tampon  of  glycerine,  facilitates 
resolution,  and  by  the  excentric  compression  which  it  exercises  on  the 
tissue,  it  stimulates  the  resolvent  action.     Resolvents  may  then  be 


620  UTERINE    DISEASES    IN    DETAIL 

applied  directly  to  the  tumefied  parts  to  complete  the  mechanical  and 
vital  action  of  dilatation. 

Recourse  must  sometimes  be  had,  notwithstanding,  to  extreme 
measures,  which  are  not  dangerous  if  applied  intelligently ;  these  are 
excision,  incision,  or  abrasion  of  the  hypertrophied  part.  In  per- 
forming incision  and  excision  the  flaps  of  mucous  membrane  should  be 
preserved  so  as  to  allow  the  full  size  of  the  orifice  to  be  retained.  In 
amputation  of  the  cervix  there  is  still  more  reason  for  preserving 
fragments  of  mucous  membrane  when  the  os  is  involved.  It  is 
different  when  the  malady  is  in  the  cervical  cavity,  or  even  at  the  os 
internum. 

When  the  hypertrophy  is  situated  in  the  cervical  cavity  or  at  the 
cervieo-uterine  orifice  we  should  commence  by  dilating  the  isthmus 
before  thinking  of  section.  Yery  often  repeated  dilatation  is  sufficient 
to  procure  a  satisfactory  result.  When  insufficient,  section,  abrasion, 
or  even  amputation  may  be  tried,  according  to  the  size  of  the  tubercle 
or  valvular  barrier.  Having  dilated  the  uterine  canal,  I  introduce  one 
of  Recamier's  large  curettes,  which  serves  me  for  a  guide,  and  prevents 
the  uterus  from  bending.  Then  with  a  short  probe-pointed  bistoury 
or  curved  tenotome,  guarded  by  the  curette  till  the  obstacle  is  reached, 
I  make  a  median  incision,  or  two  converging  incisions,  which  must 
not  be  deep ;  or  I  try  to  excise  the  tubercle,  dividing  it  from  left  to 
right.  To  facilitate  this  amputation,  or  rather  this  abrasion,  when 
the  hypertrophied  portion  is  soft,  I  have  used  one  of  Eecamier's 
curettes,  broad  and  sharp  at  the  end,  or  better  still  one  with  a  trian- 
gular fenestrated  and  sharp  extremity,  like  that  of  Marion  Sims,  with 
which  the  excrescence,  or  its  fragments  if  it  has  been  previously  di- 
vided, can  be  removed  by  trapping  each  successively  in  the  fenestrum 
and  withdrawing  the  instrument ;  or  I  sometimes  use  a  kind  of  little 
hooked  knife,  the  stem  of  which  is  flexible  enough  for  it  to  be  inclined 
in  various  directions. 

When  the  hypertrophy  is  situated  in  the  median  part  of  the  cervical 
segment  it  may  be  first  treated  with  sponge  or  laminaria  tents,  scari- 
fications, ignipunctures,  or  the  same  methods  of  abrasion  and 
section  may  be  employed  as  in  cases  of  partial  hypertrophy  of  the 
isthmus. 

III.  Atrophy  of  the  Uterus 

Atrophy  of  the  uterus  constitutes  a  morbid  state  in  which  this  organ, 
after  having  been  normally  developed,  loses,  from  various  causes,  its 
normal  dimensions  and  shape,  and  is  reduced  to  a  smaller  size. 
Scanzoni,^  from  whom  I  borrow  this  definition,  divides  atrophy  into 
excentric  and  concentric.  Excentric  atrophy,  a  thinning  of  the  walls 
with  dilatation  of  the  cavity,  is  usually  symptomatic,  either  of  hydro- 
metria  produced  by  the  accumulation  of  mucus  and  the  obliteration  of 
the  cervieo-uterine  orifice  in  the  period  of  decrepitude,  or  of  a  rapid 
and  considerable  effusion  of  blood,  with  atresia,  in  young  women,  or 
of   the  formation    and  persistence  of   a  fatty  state  after    puerperal 

diseases. 

1  Op.  cit.,  p.  71. 


HYPERTROPHY  AND  ATROPHY  621 

Concentric  atrophy,  thinning  of  the  walls  with  contraction  of  the 
cavity,  may  be  general  or  partial.  When  general,  it  is  often  accom- 
panied by  softening  and  small  apoplectic  centres.  When  partial,  it 
may  affect  the  cervico-uterine  isthmus  and  produce  flexions  of  the 
fundus  on  the  cervix,  or  contractions  and  obliterations  of  the  os 
internum. 

Sometimes  it  depends  on  a  purely  local  cause,  compression  exercised 
on  the  womb  by  tumours  situated  outside  this  organ,  by  sub-peri- 
toneal fibroids,  peritoneal  exudations,  organised  plastic  deposits  round 
the  uterus,  solid  ovarian  tumours,  or  by  large  tumours  arising  from 
the  pelvic  walls.  At  other  times  it  is  due  to  simple  senile  altera- 
tions, or  alterations  of  nutrition  produced  in  the  uterus  by  chronic 
maladies :  to  this  last  category  belong  cases  of  uterine  atrophy  brought 
on  by  a  state  of  paralysis,  a  result  which  appears  possible  from  some 
curious  cases  observed  by  Scanzoni  in  young  paraplegic  women,  in 
whom  the  fact  was  demonstrated  by  autopsy.  Jacquet  {Beitrdge  z. 
Geburtsk.,  Bd.  ii,  S.  2)  mentions  two  cases  of  atrophy  of  the  uterus  : 
in  one  ovarian  molimen  persisted,  in  the  other  it  was  wanting.  Ac- 
cording to  Chiari  ^  atrophy  may  be  observed  in  chlorotic  patients  and 
may  be  dependent  on  menstrual  disorders.  I  have  seen  a  case  of  uterine 
atrophy  due  to  amenorrhoea  dependent  on  general  as  well  as  local 
causes  ;  and  I  have  met  with  another  which  occurred  after  eight  abor- 
tions. There  is,  however,  a  special  kind  of  atrophy,  due  to  an  excess 
of  the  retrograde  evolution  which  the  uterus  undergoes  after  delivery, 
to  which  Simpson  has  referred  under  the  name  of  atrophy  from  exces- 
sive involution  or  siiperinvolution.  It  is  the  inverse  of  hypertrophy 
from  subinvolution.  It  occurs  when  the  progress  of  absorption  is 
effected,  after  delivery,  to  an  excessive  degree,  the  organ  being  reduced 
to  a  size  smaller  than  that  of  the  uterus  in  the  state  of  vacuity.  It  is 
comparatively  rare,  but  occurs  occasionally.  Simpson  ^  saw  several 
cases  in  his  practice^  one  of  which  was  confirmed  by  autopsy.^ 

Diagnosis — subjective  signs. — Suppressed  or  imperfect  menstrua- 
tion, which  is  not  established  normally  after  lactation.  The  breasts 
shrivel,  the  subcutaneous  adipose  tissue  covering  them  is  absorbed, 
the  skin  becomes  wrinkled,  the  patient  although  young  having  all  the 
appearance  of  premature  old  age.  The  whole  economy  participates  in 
the  change  that  has  taken  place  in  the  uterus,  just  as  in  women  at  the 
climacteric  when  the  functional  activity  of  this  organ  terminates. 
Sterility  results  as  a  matter  of  course.  The  health  is  aflected,  the 
patient  suffering  from  anaemia,  dyspepsia,  frequent  headaches,  and 
general  debility  of  body  and  mind. 

Objective  signs. — Vaginal  touch  reveals  an  unusually  small  cervix, 
projecting  so  slightly  beyond  the  vaginal  cul-de-sac  that  it  is  hardly 

1  Klinilc  der  Geburtsk.  in  Gyndcol.  Erlangen,  1852,  S.  271. 

2  Op.  cit.,  p.  597. 

^  Mickschik  {Wiener  Zeitschr.,  1856,  Bd.  xii,  Heft  3)  has  published  the 
autopsy  on  a  woman  24  years  of  age,  who  died  five  months  aftei*  two  deliveries. 
The  ovaries  and  the  uterus  were  atrophied.  Tlie  latter  was  30  mm.  in  length, 
40  in  width.  The  walls  were  i  inch  thick.  Microscopic  examination  showed 
fatty  degeneration  of  the  uterus  and  ovaries. 


622  UTEEINE    DISEASES    IN    DETAIL 

perceptible;  the  womb  is  small,  light  and  mobile;  it  is  difficult  to 
seize  it  by  abdominal  palpation  notwithstanding  the  thin  and  relaxed 
abdominal  wall.  The  os  is  small,  only  admitting  the  entrance  of  an 
extremely  fine  sound,  in  the  introduction  of  which  great  care  must  be 
taken  not  to  use  any  force,  for  the  walls  are  hardly  any  thicker  than  a 
sheet  of  paper.  Kiob  ^  mentions  a  case  of  the  kind,  Simpson  saw  a 
similar  case,  where  a  sound  carelessly  introduced  pierced  the  uterine 
walls  and  penetrated  the  peritoneal  cavity.  This  accident  has  happened 
more  than  once ;  fortunately  it  is  not  followed  by  such  serious  conse- 
quences as  might  be  supposed.  When  the  sound  is  used  with  all 
necessary  precaution,  it  only  penetrates  to  a  depth  of  3  to  4  centi- 
metres, which  proves  that  the  organ  is  abnormally  small. 

Treatment. — Is  there  any  means  of  bringing  the  uterus  back  to  its 
normal  condition  and  of  restoring  the  patient  to  her  former  health  ? 
When  the  uterus  is  completely  atrophied,  this  is  hardly  possible,  but 
when  only  slightly  affected  there  is  some  chance  of  cure.  In  atrophy 
of  the  uterus  due  either  to  congenital  imperfection  of  development  at 
puberty,  or  to  excessive  retrograde  evolution  during  the  puerperal 
state,  the  best  treatment  consists  in  the  use  of  the  galvanic  stem.  In 
order  to  understand  the  way  in  which  this  treatment  acts,  we  must 
remember  this  general  law:  in  uterine  therapeutics  as  well  as  in 
uterine  physiology  and  pathology,  all  continuous  and  increasing  irrita- 
tion, all  dilatation  of  the  walls  of  the  uterine  cavity  by  a  foreign  body, 
promotes  the  development  and  hypertrophy  of  the  organ.  When  the 
uterus  is  atrophied,  a  short  and  acute  irritation  like  that  produced  by 
the  introduction  of  a  sponge  tent  for  one  or  two  days  is  not  enough,  a 
more  continuous  irritation  is  required,  like  that  produced  by  the  pro- 
longed use  of  a  series  of  small  galvanic  stems  of  gradually  increasing 
length  and  thickness.  Simpson  ^  often  saw  menstruation  restored 
temporarily  or  even  permanently  by  the  use  of  this  means.  Among 
other  cases  he  mentions  a  very  remarkable  one,  in  which  the  galvanic 
pessary  was  left  several  months  or  even  years  in  the  uterus  and  in 
the  end  effected  the  restoration  of  regular  menstruation,  the  return  of 
the  organ  to  normal  dimensions  and  the  disappearance  of  all  the 
serious  accidents  which  had  for  long  disordered  the  general  health. 
Marriage  may  be  the  means  of  curing  atrophy.  Therefore  Yannoni  ^ 
has  recommended  coitus  in  atrophy  of  the  cervix  as  useful  in  hasten- 
ing the  development  of  this  organ.  Intra-uterine  injections  may  be 
beneficial,  as  well  as  stem  pessaries,  laminaria  tents,  or  other  foreign 
bodies.  Electricity  is  especially  likely  to  be  successful :  it  would  act 
probably  on  the  uterus  as  it  does  on  atrophied  muscles. 

^  Pathologische  Anatomie  der  weihlichen  sexual  Organe.  Wieii,  1864,  p.  206. 

2  Op.  cit.,  p.  637. 

3  Journal  des  connaissances  med.-chir.,  1850,  p.  19. 


GRANULATIONS    AND    FUNGOSITIES  623 


Geanulations  and  Pungosities 

Uterine  granulations  are  small  fibro-vascular  excrescences,  usually 
multiple  and  confluent,  variable  in  number  and  size,  seen  most  com- 
monly about  the  cervical  orifice,  although  they  may  be  developed  over 
the  whole  external  and  internal  surface  of  this  organ  and  even  in  the 
uterine  cavity,  either  from  a  simple  disturbance  of  its  local  life,  or 
under  the  influence  of  a  general  morbid  condition  whether  diathetic 
or  not. 

Fmigosiiies  are  only  granulations  in  a  further  stage  of  development, 
softer,  more  vascular,  bleeding  more,  situated  on  the  cervix  or  at 
different  depths  in  the  uterine  cavity.  ChomeP  says  :  "Granulations 
constitute  a  malady  proper  of  the  cervix  uteri."  He  adds,  however, 
that  a  tendency  to  similar  granulation  is  sometimes  observed  in  the 
mucous  membrane  of  the  pharynx,  and  more  frequently  in  men  than  in 
women. 

Etiology. — Predisposing  causes. — Local  predisposing  causes. — The 
vitality  of  the  uterus  with  its  remarkably  plastic  tendency,  its  struc- 
ture in  harmony  with  this  tendency,  showing  an  instability  of  organisa- 
tion, or  rather  a  continual  tendency  to  hypertrophy  and  atrophy,  the 
character  of  its  functions,  favouring  by  the  frequency,  periodicity  and 
nature  of  its  fluxions  this  tendency  to  plasticity,  are  evidently  three 
circumstances  which  predispose  the  uterus,  and  particularly  its  mucous 
membrane,  to  hypertrophy,  and  more  especially  to  granular  hyper- 
trophy. The  fibro-plastic  tissue,  which  is  chiefly  found  in  the  dermis 
of  the  mucous  membrane,  is  by  its  nature  more  predisposed  to  hyper- 
trophy than  any  other ;  for  it  constitutes  in  itself  a  state  of  transition 
between  the  blastema  and  the  fibrous  tissue,  and  manifests  anatomically, 
in  the  most  evident  way,  the  incessant  tendency  of  the  uterus  to 
organisation  or  hypertrophy.  It  is  to  this  structure  that  the  internal 
membrane  of  the  uterus  owes  the  power  of  undergoing  an  enormous 
tumefaction  from  the  moment  of  conception,  of  forming  the  decidua 
and  of  finding  the  elements  of  its  regeneration  ready  to  hand  at  the 
given  moment. 

It  is  impossible  not  to  attribute  to  these  anatomical  conditions  a 
great  influence  over  the  hypertrophic  tendency  which  characterises  all 
uterine  maladies,  particularly  those  of  its  mucous  membrane;  and 
further,  it  is  difficult  not  to  attribute  to  the  existence  of  \h&  fibro- 
plastic tissue  the  part  which  it  takes  in  the  formation  of  the  papillse 
of  the  dermis,  and  to  its  interposition  between  the  mucous  follicles  the 
special  tendency  to  granular  hypertrophy.  Thus  it  is  that  uterine 
fungosities,  i.  e.  more  or  less  fungous  granulations  of  the  cervical 
cavity  are  frequent ;  and  that  granulations  of  the  cervix  especially,  as 
the  part  most  exposed  to  external  agents  and  to  all  the  morbid  acci- 
dents capable  of  producing  them  are  more  frequent  still ;  there  is  no 
diathesis  under  the  influence  of  which  they  cannot  be  developed  or 

•  Diction,  de  med.,  en  30  vol.,  art.  Utertts,  M^iteite  GRANrLEE.  Paris,  1846. 


624  UTERINE    DISEASES    IN    DETAIL 

perpetuated  :  judging  from  my  own  experience,  out  of  nearly  3000 
cases  of  uterine  maladies  I  have  had  450  cases  of  granular  cervix. 

Oeneral  predisposing  causes.  —  Diathetic  affections  of  all  kinds 
have  a  large  share  in  the  production  and  chronicity  of  uterine  maladies. 
Almost  all  writers  on  uterine  diseases  in  the  last  few  years  have  attri- 
buted these  granulations  to  inflammation  of  the  cervix.  Since  Bennet^ 
published  his  admirable  book  on  this  disease,  metritis  has  taken  too 
large  a  place  in  the  domain  of  uterine  maladies.  Por  Aran,  Becquerel, 
Nonat,  granulations  as  well  as  redness,  erosions,  ulcers,  leucorrhoea, 
&c.,  are  but  symptoms  of  metritis.  I  am  not,  however,  alone  in  trying 
to  prove  that  inflammation  is  not  everything  in  uterine  diseases  in 
general,  and  in  the  production  of  uterine  granulations  in  particular. 
Timbart,^  although  he  admits,  contrary  to  my  opinion,  that  granula- 
tions do  not  of  themselves  form  special  and  distinct  maladies,  demon- 
strates in  the  conclusion  of  his  work  that  these  lesions  may  occur  as 
symptoms  or  complications  in  the  majority  of  uterine  affections  :  those 
affections  with  which  he  specially  connects  them  are  uterine  catarrh 
and  scrofulous  engorgement  of  the  cervix.  Fontan,  Durand-Fardel 
and  Gueneau  de  Miissy,  being  struck  with  the  coexistence  of  pharyn- 
geal and  uterine  granulations  with  skin  diseases,  think  that  they  may 
often  be  dependent  on  herpetism.  Tillot,^  like  Pidoux,  connects  them 
as  well  as  all  other  uterine  diseases  with  the  existence  of  some 
diathesis. 

Among  the  diathetic  states  which,  in  fixing  themselves  on  the 
cervix,  may  produce  uterine  granulations,  syphilis  and  catarrh  seem 
to  play  the  chief  part. — In  the  lock  wards  of  the  General  Hospital  of 
Montpellier  I  have  had  occasion  to  see  a  number  of  women  affected 
with  uterine  granulations  coexisting  with  various  syphilitic  symptoms, 
and  although  it  is  difficult  to  decide  in  all  cases  whether  there  is  simple 
coincidence  or  community  of  origin  and  nature  between  these  granula- 
tions and  the  various  manifestations  of  the  syphilitic  affection,  I 
am  inclined  to  believe  (especially  after  the  cures  which  have  followed 
the  specific  treatment  employed)  that  the  syphilitic  diathesis  had  a 
share  in  the  development  of  the  granulations.  It  is  seldom,  however, 
that  anti-syphilitic  treatment  is  sufficient  of  itself  to  overcome  this 
malady ;  this  is  doubtless  owing  to  the  hypertrophic  tendency  of  the 
uterine  tissue  under  the  influence  of  which  it  is  produced  and  has  a 
tendency  to  become  perpetuated. — Catarrh  which  attacks  the  uterus 
so  frequently,  not  only  in  multiparse  but  in  newly  married  women,  and 
even  in  girls,  is  not  only  manifested  by  a  mucous  discharge,  but  by 
the  fluxion  which  it  keeps  up  towards  the  mucous  membrane,  bring- 
ing its  hypertrophic  tendencies  into  play  and  producing  granulations. 
Timbart  justly  remarks  that  cervical  erosions  and  granulations  dia- 
gnosed  constantly   as  lesions   of    blennorrhagia  and  uterine  catarrh 

1  A  Practical  Treatise  on  Infiammation  of  the  Uterus,  its  Cervix  and  Ap- 
pendages. 

2  Des  erosions  et  des  granulations  du  col  de  Vuterus,  de  leur  valeur  nosolo- 
gique.     Theses  de  Paris,  1849. 

3  De  la  lesion  et  de  la  vialadie  dans  les  affections  chroniques  du  systcme 
uterin.     Theses  de  Paris,  1860. 


GRANULATIONS    AND   FUNGOSITIES  625 

ouglit  to  be  included  as  special  characters  in  the  history  of  these  dis- 
eases :  simple  erosion  for  the  acute  and  non-malignant  form^  and 
granulations  for  the  chronic  and  serious  form.  I  could  myself  men- 
tion cases  of  catarrhal  granulations,  and  have  no  doubt  that  granula- 
tions of  this  kind  are  at  least  as  frequent  as  others. — The  diathesis 
which  exercises  most  influence  on  the  development  of  granulations 
according  to  Chomel,  Robert,  Huguier,  Scanzoni,  Gueneau  de  Mussy, 
Durand-Fardel,  Pontan,  &c.,  is  the  herpetic,  the  external  manifestations 
of  which  these  writers  have  often  seen  coincide  with  the  existence  of 
granulations.  I  have  also  met  with  several  cases  in  which  these  two 
maladies  coexisted  (herpetism  and  granulations),  especially  in  women 
affected  with  pityriasis,  eczema,  herpes,  ciliary  blepharitis,  simulta- 
neously with  uterine  granulations,  and  who  had  no  symptoms  of  any 
other  aff'ection,  such  as  catarrh,  scrofula,  inflammation,  &c.,  or  who 
could  not  attribute  the  development  of  this  disease  to  any  local  cause, 
such  as  excessive  intercourse,  pregnancy,  &c. 

Tillot,  in  reviewing  the  various  diatheses  which  play  the  chief  part 
in  the  etiology  of  chronic  uterine  afl^ections  (granulations  amongst  the 
rest),  enumerates  them  in  the  following  order  of  frequency :  the 
strumous,  syphilitic,  herpetic,  cancerous,  &c.  In  the  production  of 
these  granulations  I  do  not  think  that  the  scrofulous  should  have  a 
more  prominent  place  assigned  to  it  than  the  other  diatheses  just 
named. — The  part  taken  by  rheumatism  and  more  rarely  by  gout, 
although  less  marked,  is  not  the  less  certain,  and  I  think  the  prac- 
titioner cannot  afford  to  ignore  it. 

Betermining  causes. — Any  cause  which  produces  a  certain  degree  of 
irritation  in  the  organ,  which  stimulates  its  vital  activity,  and  excites 
its  plastic  or  hypertrophic  tendency,  may  occasion  the  formation  of 
these  granulations.  In  this  way  dysmenorrlicea  and  other  menstnial 
disorders  suffice  to  develop  them,  and  may  be  the  only  causes  to  which 
they  can  be  attributed  in  girls.  Marital  intercourse  in  newly  married 
women  is  undoubtedly  a  determining  cause.  Owing  to  the  novelty 
of  the  act,  and  in  some  measure  to  the  traumatism  to  which  the 
cervix  is  exposed,  or  it  may  be  to  the  frequency  of  coitus  and  the 
attendant  excitement,  the  cervix  undergoes,  as  a  consequence  of  this 
anatomical  and  physiological  shock,  a  modification  in  its  vitahty  which 
brings  into  play  its  tendency  to  hypertrophy,  probably  at  the  most 
sensitive  parts,  or  at  the  orifices,  whence  it  results  that  the  urethral 
meatus  is  usually  the  starting-point  of  the  granular  formation.  In 
such  cases  especially  these  granulations  seem  to  me  to  coincide  with 
inflammation  of  the  follicles  and  uterine  discharges.  Excitement  of 
the  sexual  organs  by  venereal  excesses,  especially  the  frequent  contact 
of  the  penis  with  the  cervix,  may  have  a  share  in  the  development 
of  granulations,  but  not  more,  it  appears  to  me,  than  it  has  in  the 
development  of  other  uterine  diseases.  Pregnancy,  by  bringing  into 
play  the  hypertrophic  tendency,  should  be  the  most  common  of  all 
determining  causes.  Pregnancy  of  itself  modifies  the  life  of  women 
so  greatly,  producing  so  many  pains  and  morbid  symptoms  due  to  the 
development  of  the  uterus  and  abdomen,  that  the  majority  of  women, 

40 


626  UTEEINE    DISEASES   IN   DETAIL 

even  when  they  suffer  much,  do  not  think  of  consulting  a  physician, 
and  still  less  of  undergoing  an  examination;  therefore  it  is  difficult 
to  establish  any  conclusions  with  regard  to  this  matter.  It  may, 
however,  safely  be  affirmed  that  it  is  rare  to  examine  a  pregnant 
woman  without  finding  a  granular  cervix.  Delivery,  and  especially 
the  after  effects  of  labour,  bringing  in  their  train  engorgement,  con- 
gestion and  even  inflammation  or  hypertrophy,  may  be  regarded  next 
to  pregnancy  as  the  most  powerful  determining  causes.  Lastly,  uterine 
inflammation,  when  left  to  itself,  or  if  some  condition  of  its  develop- 
ment have  fixed  it  on  the  cervix,  may  play  the  double  part  of  occa- 
sional and  essential  cause. 

Course. — Usually  these  granulations  first  appear  at  the  os,  on  one 
of  the  lips  or  else  all  round  the  orifice.  This  is  seen  especially  in 
women  who  have  not  conceived,  in  whom  the  cervix  is  more  or  less 
conical,  with  a  narrow  circular  orifice.  They  afterwards  spread  either 
externally  or  into  the  cavity,  so  that  when  examined  they  already  form 
a  red  mammillated  patch  from  1  to  2  centimetres  in  diameter,  the 
centre  of  which  corresponds  very  nearly  with  the  os,  the  borders  being 
very  irregular  on  both  lips,  owing  to  the  unequal  development  of  the 
granulations  on  the  neighbouring  points  of  the  uterine  tissue.  At  the 
same  time  that  the  granulations  spread  over  the  surface,  whether  ex- 
ternally or  in  the  depth  of  the  cervical  cavity,  they  also  extend  in  all 
their  dimensions — that  is  to  say,  that  having  increased  in  number  they 
increase  in  size,  acquiring  sometimes  a  considerable  volume,  and  taking 
the  name  of  fungosities.  This  course  is  essentially  chronic,  offering 
no  natural  retrograde  tendency — that  is  to  say,  no  tendency  to  spon- 
taneous cure.  The  intervention  of  art  is  all  the  more  necessary  that 
the  course  of  these  granulations  is  not  always  limited  to  the  symptoms 
I  have  just  sketched.  Although  they  sometimes  exist  without  com- 
plications, they  more  generally  cause  concomitant  symptoms,  functional 
alterations  or  pathological  processes,  either  concentrated  in  their 
own  sphere  or  further  removed  from  it.  Thus  follicles,  the  orifices 
of  which  are  usually  at  the  bottom  of  the  grooves  which  separate  the 
granulations,  become  irritated  and  secrete  an  abundant,  opaline, 
whitish  mucus.  Sometimes  they  become  inflamed  as  well  as  the 
granulations  themselves ;  they  secrete  pus,  ulceration  may  attack  the 
granulated  surface,  and  the  purulent  secretion  of  this  surface  is  then 
added  to  the  muco -purulent  secretion  of  the  follicles.  This  secretion 
may  be  the  only  apparent  trace  of  organic  lesion  when  the  granulations 
or  fungosities  are  situated  in  the  interior  of  the  cervix,  and  when  the 
conditions  are  not  such  as  to  allow  of  the  gaping  of  this  organ.  The 
development  of  granulations,  which  are  an  obstacle  to  free  communi- 
cation between  the  uterine  and  vaginal  cavities,  prevents  conception 
and  may  become  a  more  or  less  painful  obstacle  to  the  expulsion  of 
uterine  mucosities,  menstrual  blood,  &c.,  even  when  it  does  not  cause 
the  still  more  serious  symptoms  of  uterine  fluxion,  tumefaction  of  the 
womb,  or  obstinate  menorrhagia  or  metrorrhagia.  This,  however, 
hardly  occurs  except  in  the  case  of  fungosities  developed  in  the  cavity 
of  the  body  of  the  uterus,  and  known  as  uterine  fungosities.     Since 


GEAXDLATIOXS    AND  FUNGOSITIES  627 

Eecamier's^  investigations  these  latter  alterations  have  been  the  object 
of  special  study.-  Although  infinitely  less  frequent  than  granulations, 
they  seem  to  form  an  analogous  malady,  and  several  times  the  gradual 
extension  from  the  one  to  the  other  has  been  observed. 

Granulations,  in  certain  cases,  cannot  long  continue  without  causing 
engorgement,  and  more  frequently  partial  or  total  hypertrophy  of  the 
cervix,  and  what  is  more  serious,  inflammation  of  this  organ  and  even 
of  the  whole  uterus.  They  are,  therefore,  a  constant  source  of  danger 
for  the  women  who  are  affected  by  them,  especially  in  cases  of  preg- 
nancy. Most  writers  agree  in  considering  granulations  and  fungosities, 
as  well  as  ulcerations,  as  possible  causes  of  abortion  in  pregnant 
women. 

Varieties. — The  seat  is  at  the  os  uteri,  especially  in  virgins  and  in 
nuUiparse :  usually  on  the  cervical  lips  in  pregnant  women  and  in 
multiparse ;  very  often  extending  farther  on  one  lip  than  on  the  other 
(the  anterior  has  seemed  to  me  more  frequently  affected  than  the 
posterior),  but  seldom  on  one  only;  often  limited  to  the  external 
surface  of  the  cervix  (especially  in  pregnant  women) ;  often  also  ex- 
tending to  a  more  or  less  considerable  height  into  the  interior  of  the 
cavity  (when  they  occur  after  delivery);  sometimes  even  reaching  to  the 
cervico-uterine  isthmus,  in  fact  they  may  be  situated  exclusively  in  the 
neck  whilst  there  is  no  external  trace ;  this  is  especially  the  case  when 
they  are  catarrhal  in  nature. 

The  number  of  the  granulations  is  usually  considerable.  Some  idea 
can  be  formed  as  to  the  variation  in  number  from  their  differences  of 
disposition  and  volume. 

The  d'ujwsition  may  differ  much  according  to  whether  the  granula- 
tions are  discrete  or  confluent.  They  are  very  seldom  discrete  :  the 
only  examples  perhaps  being  the  hypertrophic  inflammatory  pimples 
round  the  follicular  orifices,  which,  as  I  have  said,  may  be  seen  on  the 
cervix.  On  the  contrary,  they  are  almost  always  confluent,  spreading 
more  or  less  on  the  surface  of  the  cer^dx,  or  rising  more  and  more 
from  the  point  where  they  have  taken  birth  so  as  somewhat  to  resemble 
a  strawberry  or  raspberry.  Lastly,  granulations  are  seldom  seen  dis- 
seminated singly  or  in  little  groups  outside  the  principal  granulated 
surface.  This  surface  is  rounded  or  elliptical,  sometimes  irregular, 
with  jagged  edges.  It  seldom  extends  over  the  whole  cervix,  although 
it  may  greatly  exceed  the  average  extent  of  from  1  to  2  centimetres, 
especially  in  cases  of  hypertrophy.  In  colour  and  relief  it  contrasts 
strikingly  with  the  pale  colour  and  smooth  aspect  of  the  rest  of  the 
cervix  when  the  latter  is  neither  congested  nor  inflamed. 

The  size  of  the  granulations  is  usually  very  small,  about  that  of  a 
millet  seed,  seldom  equalling  that  of  a  smaU  lentil.  The  agglomera- 
tion and  confluence  of  these  little  pimples  often  give  to  a  number  of 
them  the  appearance  of  one  large  one.  However,  there  is  no  doubt 
that  the  granulations  which  are  formed  on  ulcers,  those  which  become 
fungous,  those  which  are  of  scrofulous  nature  and  those  which  are 

'   Union  medicale,  1850. 

^  Rouyer,  Des  fongosiies  uUrines.  These  de  Paris,  1858. 


628  UTERINE    DISEASES    IN    DETAIL 

found  on  an  engorged  or  oedematous  cervix,  sometimes  present  very 
considerable  dimensions. 

The  colour  of  the  granulations  is  always  more  or  less  red.  This  red- 
ness varies  little  in  successive  examinations  in  the  same  woman.  It 
may,  however,  increase  or  diminish  in  intensity,  according  to  whether 
menstruation  is  near  or  not.  Usually  this  redness  is  very  marked,  but 
sometimes  it  is  pale  pink,  at  other  times  it  is  more  or  less  purple ;  in 
this  respect  inflammatory  granulations,  for  example,  may  differ  much 
from  granulations  of  a  scrofulous  nature.  The  colour  of  the  granula- 
tions although  coutrasting  strongly  with  that  of  the  cervix  in  the 
normal  condition,  is  not  so  different  as  Chomel  has  asserted.  For  in- 
stance, during  pregnancy  they  assume  the  wine-red  aspect  which  is 
characteristic  of  the  cervix  at  that  time,  and  which  spreads,  as  we 
know,  to  the  surface  of  the  vagina  and  to  the  nymphse.  It  is  remark- 
able that  after  death  they  lose  much  of  their  colour  and  even  of  their 
volume,  especially  those  which  are  fungous. 

The  structure  of  these  granulations  may  vary  like  the  other  charac- 
teristics of  which  I  have  just  spoken.  It  is  such  as  to  impart  a  soft 
consistency  generally  to  the  granulations ;  therefore  in  practising 
digital  touch  they  may  be  torn  with  the  nail  or  be  made  to  bleed  by 
wiping  the  surface  with  cotton-wool.  Sometimes,  owing  to  the  pre- 
dominance of  fibrous  or  fibro-plastic  elements,  they  acquire  a  hardness 
which  enables  them  to  resist  these  attempts  and  prevents  their  being 
removed  by  scraping.  At  other  times  from  the  predominance  of  the 
vascular  elements,  they  become  fungous  on  the  contrary,  bleeding 
easily,  the  slightest  contact,  coitus  especially,  in  such  cases  causing  slight 
hsemorrhage,  or  at  least  the  flow  of  a  few  drops  of  blood.  Between 
these  two  extremes  there  may  be  a  number  of  degrees  and  even  varie- 
ties of  structure,  according  to  whether  the  fibrous  element,  the  epithe- 
lium, the  amorphous  matter,  the  lymph,  &c.,  have  more  or  less  share 
in  their  composition. 

As  to  the  differences  in  nature,  herpetic  granulations  are  generally 
external,  bright  red  and  only  slightly  projecting ;  scrofulous  granula- 
tions more  frequently  than  others  occupy  only  one  lip,  they  are  more 
voluminous  and  paler ;  catarrhal  granulations  are  often  more  developed 
internally  than  externally,  and  are  always  covered  by  a  more  or  less 
opaline  consistent  mucous  discharge.  Fungous  granulations  frequently 
developed  on  a  pre-existing  ulcer  often  occupy  the  cervical  cavity  also; 
they  are  voluminous,  red  and  bleeding.  Granulations  are  not  con- 
tagious unless  syphilitic. 

Diagnosis. — They  often  exist  without  giving  rise  to  any  characteris- 
tic symptom,  or  to  any  local  phenomena;  therefore  we  must  take 
sympathetic  disorders  into  account ;  however  slight  they  may  be  they 
should  never  be  neglected ;  leucorrhoea  especially  ought  to  be  taken 
into  serious  consideration  as  well  as  lumbar  pain. 

Subjective  signs. — Uterine  granulations  sometimes  cause  disordered 
menstruation.  When  fungous  they  may  determine  menorrhagia,  the  ex- 
pulsion of  clots,  &c. ;  when  they  are  hard,  hysteralgia  uterine  colics,  and 
excited  doubtless  by  the  difficulty  which  the  uterine  contractions  have 


GRANULATIONS    AND    FUNGOSITIES  629 

in  overcoming  the  spasm  or  mechanical  obstacle  caused  by  induration 
of  the  cervix.  The  pains  are  sometimes  absent  or  are  the  same  as  in 
all  uterine  maladies ;  they  seem  to  be  seated  in  the  vagina  or  deve- 
loped on  the  cervix,  especially  during  coitus.  The  remote  pains  are  in 
the  renal  region  or  in  the  thighs,  seldom  in  the  hypogastrium  or  in 
the  iliac  regions,  as  in  metritis,  peri-uterine  inflammations,  engorge- 
ments, deviations,  &c.  When  there  are  no  pains,  or  when  they  are 
concealed,  for  example  by  pregnancy,  the  trouble  may  be  ignored, 
manifested  only  by  general  discomfort,  want  of  appetite,  paleness, 
emaciation  and  all  the  consequences  of  the  sympathetic  disturbance  of 
the  digestive  and  nervous  functions. 

There  is  one  general  symptom  which  is  not  pathognomonic  but 
which  is  frequently  the  consequence  of  granulations,  viz.  sterility.  It 
is  owing  to  the  mechanical  and  physiological  difficulties  in  the  way  of 
fecundation  formed  by  the  granulations  fitting  into  each  other,  the 
viscosity  and  adhesiveness  of  the  mucus  which  covers  the  surface  and 
forms  a  gelatinous  stopper  and  by  the  irritability  and  spasm  pro- 
duced in  the  cervico-uterine  sphincter. 

Objective  signs. — A  red,  granular  surface,  commencing  at  the  os 
uteri  and  radiating  over  a  more  or  less  considerable  extent  of  the 
cervix,  formed  of  small  granulations  usually  confluent,  seldom  discrete, 
rarely  attacking  the  whole  cervix,  but  forming  a  kind  of  patch  or 
mammillated  elevation  somewhat  like  a  raspberry,  surrounded  on  all 
sides  by  a  healthy  annular  surface  of  the  cervix.  A  more  or  less 
abundant  glairy,  muco-purulent  or  purulent  discharge  almost  always 
covers  it,  and  must  be  removed  before  the  granular  surface  can  be 
seen.  This  discharge  which  is  seldom  pus,  but  which  may  be  opaque, 
semi-transparent  or  opaline,  is  often  clear  like  white  of  egg.  In  the 
latter  case  it  is  seldom  that  it  is  not  sufficiently  abundant  to  be  dis- 
charged from  the  vulva  moistening  the  inner  surface  of  the  thighs, 
and  leading  the  patient  to  think  she  must  have  some  uterine  disease. 
The  finger  with  difficulty  determines  the  circumference  of  the  granula- 
tions, but  can  easily  discover  the  elevations  round  the  cervix  or  in  its 
orifice ;  the  sensation  felt  by  the  tip  of  the  finger,  and  which  has  been 
compared  to  that  produced  by  shagreen  leather,  is  more  like  that 
communicated  by  Utrecht  velvet  (Chomel) ;  the  finger  almost  inevit- 
ably brings  away  a  few  drops  of  blood  from  the  nail  slightly  scraping 
the  diseased  surface :  it  is  easy  by  sight  and  touch  to  distinguish 
granulations  of  the  cervical  cavity  from  simple  leucorrhoea. 

Differential  diagnosis. — Granulations  must  be  distinguished  from 
vegetations,  ulcers,  erosions  and  the  various  eruptions  which  may  have 
their  seat  on  the  mucous  membrane  of  the  cervix,  such  as  pemphigus,, 
eczema  and  especially  herpes. 

Vegetations  are  only  vascular  epithelial  excrescences.  When  the 
epithelial  development  is  not  accompanied  by  a  rich  vascular  develop- 
ment there  results  a  hard  production  of  a  dull  leathery  white,  some- 
thing like  a  flattened  wart,  developed  on  one  of  the  lips  or  on  one  of 
the  sides  of  the  cervix  rather  than  at  the  orifice.  In  the  rare  cases 
when  great  vascularity  is  added  to  epithelial  exuberance,  vegetations  of 


630  UTEEINE    DISEASES    IN    DETAIL 

the  cervix  have  the  familiar  appearance  of  vegetations  of  the  vulva  and 
prepuce,  and  consequently  are  distinguished  by  their  projection,  their 
subdivisions,  by  real  granulations  and  even  by  uterine  fungosities.  As 
for  the  other  vegetating  excrescences  which  do  not  depend  on  syphilis, 
like  the  majority  of  the  vegetations  of  which  we  have  spoken,  and 
which  under  the  names  of  fungosities,  cauliflower  excrescences,  &c.^  are 
only  manifestations  of  the  more  or  less  rapid  increase  of  uterine  cancer, 
it  is  still  more  difficult  to  confound  them  with  granulations  of  the 
cervix. 

Polypi  are  pediculated  tumours  of  a  more  or  less  considerable  size, 
resulting  usually  from  the  hypertrophy  of  one  of  the  anatomical  ele- 
ments of  the  uterus,  and  developing  gradually  without  any  diathesis  or 
morbid  state  other  than  hypertrophy  pure  and  simple.  It  is  the 
same  with  ihe,  follicular  cysts  described  by  Huguier. 

Various  vesicular  and  pustular  eruptions,  such  as  herpes,  eczema, 
pemphigus,  &c.,  may  appear  on  the  cervix  leaving  a  red  surface,  which 
bleeds  easily,  and  which  is  sometimes  confounded  with  granulations 
strictly  so  called  and  classed  with  these  latter  by  some  writers,  and  more 
or  less  distinguished  from  them  by  other  authors  under  the  name  of 
erosions,  exuberations,  &c.  It  is  always  easy  to  verify  the  charac- 
teristic course  of  these  maladies,  the  gradual  development  of  vesicles, 
pustules,  follicular  eruptions,  however  small  and  confluent  they  may 
be,  the  flat  bleeding  surface  which  results,  the  distinct  borders  of  the 
erosion,  the  absence  of  more  or  less  thick  mucous  secretion,  the  epi- 
dermic denudation ;  lastly,  the  absence  of  exuberances  due  to  the  de- 
velopment of  the  anatomical  elements,  the  existence  of  which  is  verified 
in  the  granulations. 

Ulcers  may  attack  a  more  or  less  extensive  portion  of  the  cervix,  in 
some  circumstances  presenting  at  first  sight  so  much  apparent  analogy 
with  uterine  granulations,  that  several  writers  have  not  distinguished 
granulations  strictly  so  called  from  granular  ulcers.  Now,  at  the  com- 
mencement of  their  development,  ulcers  may  present  the  appearance  of 
some  of  the  eruptions  first  named,  but  with  the  progress  of  the  patho- 
logical process  which  produces  and  keeps  them  up  they  soon  assume 
a  characteristic  form,  an  inspection  of  which  is  usually  suflicient  to 
distinguish  them. — There  is,  however,  a  period  when  ulcers  may 
assume  characters  which  make  them  resemble  granulations :  it  is 
when  they  become  really  granular,  either  from  being  covered  by  true 
cicatricial  granulations,  which  will  soon  produce  a  real  cicatrix,  or 
because  they  become  the  seat  of  a  more  or  less  luxuriant  vegetation, 
which  makes  the  healthy  granulations  persistent,  extensive,  bleeding, 
sometimes  considerably  exceeding  the  limits  of  the  ulcer. 

Healthy  granulations,  to  borrow  the  description  given  by  my  friend 
and  colleague  M.  Charles  Eobin,  "  are  conical  and  reddish  eleva- 
tions developed  on  the  surface  of  suppurating  wounds  where  they 
determine  cicatrisation.  They  are  formed  all  the  more  quickly  when  the 
tissue  is  cellular  and  vascular ;  at  first  broad,  soft  and  only  slightly 
projecting,  they  soon  constitute  by  their  union  a  kind  of  membrane 
provided  with  blood-vessels.     They  are  composed  :  1,  of  a  large  pro- 


GRANULATIONS    AND    FUNGOSITIES  631 

portion  of  amorphous  granular  matter ;  S,  of  fibrillse  of  cellular  tissue 
of  new  formation  interlaced ;  3,  of  fibro-plastic  elements  with  rather 
large  and  pale  nuclei ;  4<,  of  capillaries.  They  increase  in  size  by  the 
production  of  new  elements  added  to  those  of  the  same  kind  throughout 
the  whole  thickness  of  their  mass.  The  surface  of  these  rudiments  of 
cicatricial  tissue  is  covered  with  pus  and  gradually  with  epithelial 
cells,  which  soon  exceeding  the  pus  in  quantity  form  a  thin  and 
whitish  pellicle  of  epidermis  continuous  with  that  of  the  skin  :  this  is 
called  cicatrisation.  As  this  epidermic  pellicle  is  formed  the  granula- 
tions disappear,  owing  to  the  slow  but  energetic  disappearance  of  the 
molecules  of  the  amorphous  matter  by  absorption,  and  the  consequent 
bringing  together  of  the  fibrous  elements ;  this  is  what  determines 
retraction  of  the  borders  of  the  wound,  leading  to  the  belief  in  the 
contractility  of  cicatricial  tissue.''  Absorption,  continuing  after  cica- 
trisation is  concluded,  determines,  as  I  think  I  was  the  first  to  teach,^ 
contraction  of  the  cicatrix.  Uterine  granulations  which  are  developed 
on  the  cervix  are  composed,  like  true  cicatricial  granulations,  of  the 
elements  of  fibrous  tissue  which  enter  into  the  composition  of  the 
cervix,  of  fibro-plastic  elements  whether  pre-existing  or  of  new  forma- 
tion, of  fibrillse  of  cellular  tissue  newly  developed,  and  of  granular 
amorphous  matter.  These  elements,  constituting  a  kind  of  hyper- 
trophy of  the  dermis  of  the  mucous  membrane,  are  traversed  by  capil- 
laries, the  variable  number  of  which  renders  cicatricial  tissue  more  or 
less  prone  to  bleed  at  the  slightest  contact.  It  is  covered  by  epithe- 
lium, in  which  cells  of  new  formation  often  strengthen  the  layer  of  the 
old  cells ;  the  thickness  of  the  epithelium  which  results  does  not  pre- 
vent the  granulations  from  bleeding  when  rubbed  with  the  tip  of  the 
finger  or  when  wiped  with  cotton  wool,  because  the  cells  of  new  forma- 
tion are  always  so  soft  and  delicate  as  to  ofier  but  little  resistance ; 
sometimes  even  the  subjacent  connective  tissue  is  laid  bare  by  a  super- 
ficial erosion. — There  is  therefore  a  great  resemblance  between  uterine 
granulations  and  the  granulations  of  cicatricial  tissue.  Uterine  granu- 
lations, however,  besides  being  real  tissue  developed  at  the  expense  of 
the  fibro-plastic  or  embryonic  elements,  are  hypertrophied  papillae  of 
the  dermis,  either  simple  epithelial  elements,  like  those  entering  into 
the  structure  of  vegetations,  or  hypertrophied  vascular  elements  of  the 
papillae  or  capillaries  interposed  between  the  follicles  or  surrounding 
them,  or  else  real  hypertrophied  follicles  always  characterised  by  a  point 
at  the  summit  of  the  granulation,  the  point  being  only  the  orifice  of 
the  follicle. 

Prog7iosis. — Uterine  granulations  do  not  involve  any  serious  danger ; 
but  they  have  a  tendency  to  increase,  they  last  a  long  time,  often  with- 
standing rest  and  treatment ;  they  are  inconvenient  from  the  mucous 
and  sometimes  sanguineous  discharges  which  accompany  them ;  they 
cause  more  or  less  marked  general  debility,  and  prevent  conception 
taking  place.  This  prognosis  makes  it  the  duty  of  the  physician  to 
persuade  patients  to  undergo  necessary  treatment. 

^  Clinique  chirurgicale. — Be  la  formation  des  cicatrices,  de  lev/r  retractilite 
et  des  difformites  qui  en  rhultent,  p.  291.  Montpellier,  1851. 


632  UTEEINE    DISEASES    IN  DETAIL 

Treatment — the  indications. —  According  to  1,  the  nature  of  these 
granulations  or  the  diversity  of  the  affections  or  morbid  processes  by 
which  they  are  kept  up;  2,  the  analogy  and  variations  of  structure 
which  they  present  in  various  cases ;  and  3^  the  hypertrophic  tendency 
which  characterises  them,  it  is  evident  that  each  of  these  three  terms 
becomes  the  source  of  indications  in  proportion  to  the  share  which 
inflammation  has  in  its  development. 

I.  I  shall  not  speak  of  the  treatment  to  be  used  in  subduing  the 
nature  of  the  malady,  except  to  mention  that  my  opinion  is  contrary 
to  that  of  those  gynaecologists  who  regard  uterine  granulations  as 
granular  metritis  to  be  treated  by  antiphlogistics  local  and  general 
which  usually  produce  no  effect.  Nevertheless  when  metritis  exists, 
the  inflammation  should  be  treated  by  leeching  the  cervix,  emollient 
baths,  with  prolonged  irrigations,  the  application  of  mercurial  oint- 
ment to  the  abdomen,  groins  and  thighs,  and  by  revulsive  purgatives. 
After  the  cure  of  the  metritis  it  will,  however,  be  necessary  to  treat 
these  granulations  by  suitable  local  means.  In  other  cases  we  must 
treat  the  catarrhal  affection  or  the  constitutional  diathesis  whether 
scrofulous,  rheumatic,  herpetic  or  syphilitic  before  using  local  means 
or  at  least  simultaneously  with  them.  I  could  mention  many  cases  in 
which  patients  have  only  been  definitely  cured  after  having  undergone 
general  treatment  by  mercury,  iodide  of  potassium,  cod-liver  oil,  iron, 
sea  bathing,  mineral  waters,  hydropathy,  &c.  It  is  the  same  with  the 
chronic  form,  which  may  exist  without  being  dependent  on  any  dia- 
thesis and  without  presenting  any  inflammatory  character  which  would 
allow  of  its  being  considered  with  chronic  metritis  as  some  writers 
have  done.  In  such  cases  the  organ  may  no  longer  be  inflamed,  even 
if  it  has  previously  been  so,  but  it  retains  the  habit  of  fluxionary 
movements,  congestion,  engorgement,  hypertrophy,  which  are  all  the 
more  difficult  to  eradicate  because  favoured  by  a  condition  of  anaemia, 
chloro-auEemia  and  general  debility.  When  this  is  the  case  restorative 
medication,  tonics,  a  generous  diet,  iron,  hydropathy,  hot  vaginal 
injections,  blisters  on  the  cervix,  astringent  and  resolvent  applications, 
with  inert  powders,  and  igni-punctures  to  destroy  the  granular  surface 
produce  the  best  results. 

II.  As  to  the  second  indication,  the  state  of  hypertrophy  which 
characterises  uterine  granulations  and  the  hypertrophic  tendency  of 
the  cervix  which  their  existence  increases,  necessarily  indicate  the 
application  of  means  the  resolvent  properties  of  which  have  the  faculty 
of  determining  a  tendency  to  absorption  or  atrophy.  Therefore 
astringents  of  all  kinds  are  employed  in  injections,  e.g.  the  decoction 
of  red  roses,  oak  bark,  rhatany,  solutions  of  tannin,  alum,  nitrate  of 
silver,  &c.,  sulphur  and  iron  waters  whether  natural  or  artificial  have 
often  been  tried,  although  perhaps  no  case  of  cure  can  be  attributed  to 
them.  Astringent  powders,  such  as  tannin  and  alum ;  solvents,  such 
as  mercurial  and  iodide  ointments,  have  also  been  applied  unsuccess- 
fully to  the  seat  of  disease.  They  have  the  drawback  not  only  of 
acting  very  superficially  on  a  lesion  of  considerable  depth,  but  of 
necessitating  the  presence  of  a  tampon  in  the  vagina,  the  contact  of 


GEANDLATIONS  AND    FUNGOSITIES  633 

which  only  irritates  the  cervix  and  the  neighbouring  parts,  while  it 
prevents  other  means  of  treatment  (injections  and  irrigations)  from 
which  the  patient  would  derive  more  benefit.  Vaginal  injections  made 
on  the  bidet  morning  and  evening  with  very  hot  water  and  a  little 
carbolic  acid  is  an  excellent  way  of  combating  the  congestion  of  the 
cervix  and  removing  purulent  liquids,  the  contact  of  which  helps  to 
keep  up  the  granulations :  but  this  is  often  insufficient  to  obtain  a 
cure. 

III.  The  third  indication,  to  subdue  the  hypertrophic  tendency  of 
the  granulations,  leads  to  the  necessity  of  cauterisation,  the  most 
powerfully  destructive  as  well  as  alterative  local  means  that  can  be 
used.  I  have  given  up  the  use  of  liquid  caustics  with  the  exception  of 
Tinct.  Ferri  Perchlor.,  Tinct.  lodi,  the  concentrated  solution  of  nitrate 
of  silver,  and  a  few  others  which  only  act  slightly  on  the  healthy  sur- 
faces covered  with  epithelium.  Solid  caustics  are  either  insufficient, 
like  melted  nitrate  of  silver,  or  too  active  like  the  Vienna  paste  or 
chloride  of  zinc.  These  latter  caustics  as  well  as  arsenic  and  crystal- 
lised chromic  acid,  may  be  of  great  service  in  the  treatment  of  cervical 
ulcerations;  but  in  the  treatment  of  granulations,  the  actual  cautery 
seems  to  me  very  superior. 

The  actual  cautery  is  in  fact  that  which  requires  least  precaution, 
the  action  of  which  is  the  most  easily  limited  throughout  its  whole 
extent,  and  that  in  which  the  consequences  seem  most  favorable  to 
speedy  and  complete  cure  on  account  of  the  nature  of  the  cicatrix  and 
of  the  good  results  experienced  by  the  neighbouring  tissues,  nor  do  I 
know  any  drawback  that  it  has.  It  is  usually  sufficient  to  use  it  once, 
in  order  to  destroy  the  granulations  and  to  modify  the  underlying 
tissues  sufficiently.  On  the  other  hand  I  have  often  seen  less  energetic 
but  frequently  repeated  cauterisation  cause  fluxionary  and  inflamma- 
tory symptoms  which  never  follow  the  use  of  the  red  iron.  Cure  is 
very  rapid.  Taking  the  average  of  several  hundreds  of  cases  it  follows 
in  six  weeks,  i.e.  in  the  simplest  cases  and  it  may  be  obtained  in  three 
weeks ;  in  complicated  cases  requiring  general  treatment  and  a  second 
cauterisation  it  may  be  delayed  for  three  months.  The  surgeon  is 
complete  master  of  the  caustic ;  by  varying  the  form  of  the  cautery, 
the  degree  of  heat  applied,  the  duration  of  the  application,  &c.  he 
can  make  the  application  as  superficial  or  as  chief,  as  limited  or  as 
extensive  as  he  wishes.  When  made  nothing  is  left  in  the  vagina  and 
uterus  but  the  scar,  so  we  have  neither  to  consider  how  to  get  rid  of 
the  rest  of  the  caustic,  nor  to  contrive  means  for  retaining  it. 

The  actual  cautery  may  even  be  applied  exceptionally  in  cases  of 
pregnancy  when  formidable  symptoms  such  as  obstinate  vomiting 
seems  produced  or  kept  up  by  granulations.  I  have  long  ago  proved 
not  only  the  innocuity  and  utility  of  the  actual  cautery  applied  to  the 
cervix  even  during  pregnancy,^  but  also  the  consecutive  accomplish- 
ment of  the  normal  phenomena  of  parturition  in  pregnant  women  in 
whom  granulations  had  been  treated  by  cauterisation.^ 

'  Annales  cliniques  de  Montpellier,  Aug.  25,  1853. 
»  Ibid.,  April  10,  1854. 


634  UTEEINE    DISEASES    IN    DETAIL 

Lastly,  when  it  is  a  question  of  uterine  fungosities  situated  in  the 
cavity  of  the  body  and  causing  haemorrhage,  cauterisation  is  too  pain- 
ful and  difficult  to  be  applied  so  deeply.  In  such  cases  we  should 
commence  by  removing  these  fungosities  with  Eecamier's  or  Sims^s 
curette,  and  afterwards  modify  the  surface  of  the  mucous  membrane 
by  a  caustic  injection. 


Ulceration  and  Ulcers  oe  the  Uterine  Cervix 

An  ulcer  is  a  morbid  state  characterised  by  a  loss  of  substance  of 
variable  extent  as  regards  both  width  and  depth,  kept  up  if  not  pro- 
duced by  some  internal  cause  or  by  local  morbid  action,  and  usually 
excreting  a  more  or  less  purulent  fluid. 

Ulceration  is  the  pathological  action  which  produces  the  ulcer.  It 
is  an  alteration  in  the  nutritive  process  as  when  decomposition  is  iu 
excess  of  composition,  disassimilation  of  assimilation.  I  may  say  of 
ulceration  what  I  have  already  said  of  leucorrhoea,  engorgement,  in- 
flammation, that  this  malady  may  be  developed  at  the  close  of  another 
malady  of  which  it  seems  to  be  the  result  or  termination ;  but  it  may 
also  be  developed  all  at  once  under  the  influence  of  general  causes  and 
a  local  tendency.  Sometimes  it  remains  simple,  pursuing  its  natural 
course,  and  passing  through  the  various  phases  of  its  development 
without  necessarily  leading  to  new  disturbances  in  the  organ ;  some- 
times on  the  contrary  it  is  accompanied  by  other  morbid  states  either 
as  consequences  or  simple  complications.  It  therefore  happens  that 
ulceration  usually  coincides  with  other  diseases,  and  that  if  not  the 
result  of  them  it  cannot  last  long  without  producing  them. 

But  it  would  be  wrong  to  conclude  from  these  coincidences  that 
ulceration  is  the  primary  cause  of  these  maladies  as  the  ancients  did, 
or  as  some  gynaecologists  in  our  own  time  have  done ;  nor  would  it  be 
correct  to  conclude  with  Bennet,  Aran  and  Nonat  that  it  is  the  result 
of  inflammation,  nor  with  Lisfranc  and  Duparcque  that  it  is  the  con- 
sequence of  engorgement,  or  with  Gosselin,  Tyler-Smith  and  others, 
that  it  is  produced  by  leucorrhcea;  while  West's  opinion,  that  ulcers 
of  the  cervix  are  of  no  importance,  ought  to  be  refuted  coming  as  it 
does  from  a  writer  so  justly  entitled  to  respect. 

If  we  investigate  facts  we  shall  admit  with  West  that  ulceration  of 
the  cervix  is  very  common ;  but  we  shall  not  like  him  deduce  from 
this  fact  of  frequency  that  it  is  unimportant.  I  do  not  mean  to  say 
that  its  frequency  necessarily  involves  its  importance.  Its  importance 
depends  on  several  causes :  in  the  first  place  undoubtedly  on  the 
frequency  of  the  lesion  (we  should  always  pay  attention  to  a  malady 
which  occurs  often) ;  then  on  its  varieties  of  aspect,  on  the  difl'erent 
causes  which  produce  it,  on  its  incurability  when  left  to  itself;  lastly, 
on  the  necessity  of  applying  a  suitable  local  treatment.  I  have  often 
endeavoured  to  measure  the  degree  of  importance  which  should  be 
attached  to  ulceration  of  the  cervix;  I  have  frequently  treated  the 
engorgement,  inflammation,  leucorrhcea,  without  treating  the  ulcer;  I 


ULOBEATION  AND    ULCERS    OF    THE    UTERINE   CERVIX        635 

have  often  employed  the  most  powerful  alterative  general  treatment, 
injections  even,  and  I  may  say  that  I  have  hardly  ever  succeeded  in 
curing  the  ulcer  by  these  means  alone.  Local  treatment,  cauterisation 
and  dressings  have  seemed  to  me  indispensable  in  the  great  majority 
of  cases. 

1.  Erujotions  on  the  Cervix 

Eruptions  of  various  kinds  may  be  developed  on  the  cervix.  When 
we  are  fortunate  enough  to  see  their  first  appearance  we  can  form  an 
idea  of  the  variety  of  forms  which  they  assume,  and  when  we  compare 
them  with  those  which  are  seen  on  the  skin  or  on  other  mucous  mem- 
branes, we  are  disposed  to  admit  the  difi'erence  of  causes  which  influ- 
ence their  development.  These  eruptions  and  other  modifications  in 
the  structure  of  the  cervix  are  conditions  which  prepare  the  way  for 
ulceration. 

The  most  simple  of  these  modifications  of  the  cervix  is  redness  or 
erythema,  whether  due  to  hyperemia,  real  erythema  or  to  a  large 
ecchymosis,  or  to  a  special  congestive  condition  with  softening  of  the 
tissue  and  a  tendency  to  bleed.  In  addition  to  these  morbid  condi- 
tions there  may  also  be  leucorrhoea ;  under  the  influence  of  which  an 
abrasion  of  the  epithelium  of  the  mucous  membrane  is  sometimes  pro- 
duced vehich  gives  rise  to  the  superficial  exulceration  designated  by  the 
name  of  erosion.  Herpes,  which  is  one  of  the  forms  of  the  vesicular 
variety,  is  very  common  on  the  cervix :  it  is  constituted  by  a  heap  of 
small  vesicles,  all  confluent,  or  some  of  which  are  discrete,  grouped 
irregularly,  forming  a  surface  covered  with  small  hollow  eminences 
filled  with  transparent,  citrine,  whitish  or  slightly  purulent  serosity. 
It  is  limited  by  sinuous  or  jagged  borders,  rather  redder  than  the 
neighbouring  parts  but  gradually  blending  with  the  natural  colour  of 
the  rest  of  the  cervix.  It  is  situated  on  one  of  the  lips,  in  the  central 
and  most  convex  part,  or  near  the  orifice  more  frequently  than  on  the 
external  border.  It  resembles  the  herpetic  eruption  on  the  prepuce, 
and  though  it  sometimes  becomes  the  starting-point  of  an  ulcer  it  is 
often  cured  spontaneously,  disappearing  in  a  few  days,  which  is  un- 
doubtedly the  reason  why  it  has  not  been  seen  more  frequently. 

Eczema,  whether  simple  or  impetiginous,  is  also  developed  on  the 
cervix.  It  is  hardly  ever  seen  in  its  first  stage;  but  is  known  by  its 
extent,  secretion,  and  the  denudation  of  the  dermis.  In  place  of  being 
confined  like  herpes  to  a  small  surface  or  to  one  of  the  lips,  it  usually 
extends  over  the  whole  of  one  of  the  lips  or  over  both.  The  surface 
is  often  covered  by  a  fluid  or  semi-fluid  secretion,  which  must  be  wiped 
off  before  the  dermis  can  be  seen. 

Pemphigns,  of  which  I  have  seen  some  cases,  has  been  described  by 
Joulin.^  It  is  constituted  by  one  large  and  transparent  vesicle,  formed 
by  an  elevation  of  the  epithelium,  containing  a  serous  fluid  like  water. 
It  has  a  globular  or  rather  elliptical  form,  with  irregular  borders,  re- 
sembling somewhat  a  large  and  thick  drop  of  transparent  and  thready 

'  Academie  de  medecine,  April  2,  18G1. 


636 


UTEEINE    DISEASES    IN    DETAIL 


mucus  secreted  by  the  cervix.  It  is  sometimes  surrounded  at  its  base 
by  a  very  narrow  bright-red  border,  which  appears  to  consist  of  pure 
blood.  The  surface  of  the  cervix  on  which  it  rests  is  perfectly  normal, 
preserving  its  usual  hue,  and  may  show  absolutely  no  alteration.  The 
portion  of  epithelium  which  serves  as  a  wall  to  the  vesicle  is  so  re- 
sistant that  rubbing  with  cotton  wool  will  not  always  rupture  it ;  if 
rubbed  with  the  crayon  of  nitrate  of  silver  the  bulla  is  destroyed  im- 
mediately, and  the  fragments  of  epithelium  which  are  observed  after 
this  rupture  form  the  only  appreciable  alteration.  The  fluid  dis- 
charged does  not  appear  to  be  viscous ;  it  seems  to  possess  the  proper- 
ties of  ordinary  serum. — Uterine  pemphigus  is  a  rare  disease.  Nelaton, 
Castelnau  and  Braun^  have  observed  a  few  cases. — It  seems  always 
to  terminate  spontaneously  in  three  or  four  days  without  leaving  any 
traces ;  it  is  accompanied  by  no  symptom  perceptible  to  the  patient. 
It  is  therefore  only  accidentally  observed  on  applying  the  speculum  for 
some  other  cause. 

Folliculitis,  true  acne  of  the  cervix,  may  assume  various  forms,  from 
the  most  simple,  that  of  punctated  acne,  to  that  of  hypertrophic  acne, 
depending  on  the  share  which  inflammation  and  the  secretion  of  the 


Fig.  357. — Indurated  acne  of  the  cervix  in  a  woman  42  years  of  age.  Slight 
retroflexion  and  induration  of  the  uterus.  Eound  the  os  externum 
there  is  considerable  tumefaction,  almost  like  a  mushroom,  extending  to 
the  vaginal  portion  as  well  as  to  the  cervical  cavity,  and  dotted  over  with 
a  number  of  Naboth's  eggs,  some  containing  mucus,  others  pus  (Virchow). 

follicles  take  in  the  malady.— Sometimes  the    follicles  are  tumefied, 
prominent,  and  secrete  more  abundantly  than  usual ;  we  then  see  rising 

1  Medical  Jahrhucher,  S.  182.  Vienna,  1861. 


ULCERATION  AND  ULCERS  OF  THE  UTERINE  CERVIX    637 

from  the  cervix  discrete  or  confluent  eminences  formed  by  these  organs, 
and  small  drops  of  a  thick,  viscous^  transparent  fluid  oozing  from  their 
orifices  ;  the  colour  of  these  little  eminences  or  their  orifices  is  often 
slightly  redder  than  that  of  the  neighbouring  parts  of  the  mucous 
membrane,  but  frequently  it  does  not  greatly  differ  from  it.  Some- 
times the  follicles,  and  especially  their  mouths,  are  very  red  as  well  as 
prominent :  this  bright  redness  contrasts  so  much  with  that  of  the 
mucous  membrane  surrounding  them,  that  they  might  be  taken  for 
granulations  or  papillary  eminences  analogous  to  those  of  granular 
vaginitis.  These  eminences  may  be  confluent,  like  granulations  of  the 
cervix ;  greatly  hypertrophied,  of  a  light  red  or  violet  colour,  complex 
like  acne  of  the  nose  with  considerable  dilatations  of  the  capillary  net- 
work, or  of  the  superficial  venous  network ;  but  usually  they  are  dis- 
crete and  scattered,  and  by  this  character,  which  attracts  the  attention 
of  the  physician,  the  differential  diagnosis  between  these  two  diseases 
is  facilitated.  On  pressure  purulent  mucus  is  seen  to  escape,  in 
the  form  of  a  small  yellow  drop ;  each  small  eminence  then  forms  a 
well-marked  red  border  round  each  little  drop  that  escapes  from  its 
summit,  i.  e.  from  its  centre. 

This  malady  is  quite  distinct  from  the  uterine  granulations  already 
described. 

The  other  pustular  diseases  of  the  cervix  are  very  numerous,  and  are 
the  most  common  origin  of  ulcers  properly  so  called.  Usually  they  con- 
sist in  the  development  of  a  great  number  of  small,  contiguous,  con- 
fluent pustules,  easily  torn,  and  exuding  pus  as  in  impetigo,  and 
becoming  the  starting-point  of  a  purulent  secretion  renewed  incessantly 
on  a  base  which  is  ulcerated  and  complicated  by  granulations,  follicu- 
litis, mucous  hypersecretion,  &c.  At  other  times  they  present  the 
appearance  of  isolated  pustules,  broad  and  flat,  resembling  those  of 
ecthyma,  and  terminating  at  times  like  the  preceding ;  but  this  form 
is  much  rarer  than  the  other.  It  is  probable  that,  independently  of 
eruptions  due  to  disordered  local  vitality,  various  eruptive  forms  are 
developed  on  the  cervix  under  the  influence  of  a  diathetic  affection. 
The  mucous  membrane  of  the  cervix  resembles  the  skin  as  regards  her- 
petism  and  scrofula.  As  for  venereal  affections  I  may  say  that  I  have 
seen  every  kind  of  syphilide  on  the  cervix,  from  erythema,  small  cir- 
cular patches,  red  and  like  ruheola,  macula,  spots,  &c.,  to  pityriasis, 
psoriasis,  flat  pustules  and  tuhercles.  In  examining  women  in  whom 
the  uterus  is  supposed  to  be  healthy,  as  well  as  those  in  whom  it  is 
diseased,  we  cannot  fail  to  meet  with  these  various  eruptive  forms, 
sometimes  isolated,  sometimes  coexisting  with  a  uterine  malady,  or 
partly  assuming  another  form,  or  complicated  with  granulations  or 
ulcers. 

2.    Ulcers  of  the  Cervix 

Ulceration  of  the  cervix  is  one  of  the  most  common  diseases  of  this 
organ,  in  spite  of  what  has  been  said  by  Robert  Lee,  whose  statistics 
are  opposed  to  those  of  West.     I  may  say  that  my  own  experience  has 


638  UTERINE    DISEASES  IN    DETAIL 

confirmed  the  results  arrived  at  by  West,  and  has  justified  the  opinion 
that  ulceration  of  the  cervix  is  a  morbid  condition  of  great  importance 
in  uterine  pathology.  The  following  are  the  results  of  some  statistics 
on  the  frequency  of  ulcerations  of  the  cervix,  relatively  to  uterine  and 
other  diseases. 

Compared  with  uterine  diseases  we  find : 

According  to  my  experience  .  425  ulcerations  out  of  1563  uterine  diseases. 
„        H.  Benneti  .     .  222  „  „         300 

„        West2.     ...     17  „  „  29 

Compared  with  other  diseases  we  find  : 

According  to  West    ...     17  cervical  ulcerations  in  65  autopsies. 
„  D.  S.  Stewart'  15  „  „  60 

„  „  Aran^     ...     1  „  „  10         „ 

Diagnosis — subjective  signs. — Superficial  ulcerations  or  erosions, 
exulcerations  and  fissures  generally  pass  unperceived,  like  the  erup- 
tions which  have  given  rise  to  them.  Ulcers  properly  so-called  may 
exist  for  a  long  time  without  having  determined  leucorrhoea,  men- 
strual disorders,  local  pain,  or  general  disturbance  of  the  health  which 
would  have  attracted  attention  to  them.  This  usual,  though  not 
constant,  tolerance  of  the  organism  with  regard  to  recent  uterine 
ulceration  makes  the  description  of  the  symptoms  which  characterise 
it  difficult.  The  frequency  of  complications  is  another  cause  which 
increases  the  difficulty.  It  is  seldom  indeed  that  ulceration  exists 
alone  for  any  length  of  time.  When  it  has  lasted  for  some  time  and 
is  at  all  extensive,  there  is  at  least  leucorrhoea.  All  the  follicles  con- 
tained in  the  ulcerated  tissue  and  those  of  the  neighbourhood  are 
attacked  by  a  morbid  irritation,  which  determines  on  their  part  a 
hypersecretion  the  products  of  which  are  added  to  the  pus  secreted 
by  the  surface  of  the  ulcer.  I  do  not  speak  of  congestion,  fungos- 
ities,  softening,  hypertrophy  of  the  organ,  metritis,  nor  of  other 
complications  or  concomitant  morbid  states  giving  rise  to  special 
symptoms  previously  enumerated.  I  try  to  distinguish  the  special 
symptoms  of  the  ulcer  from  those  which,  although  they  may  have  first 
attracted  attention  to  the  uterine  malady,  may  depend  only  on  com- 
plications. Now  in  those  cases  in  which  I  have  not  had  to  separate 
the  ulcer  from  any  other  concomitant  morbid  state,  but  have  treated  it 
directly  without  being  first  obliged  to  resort  to  leeching  or  other 
medication,  I  have  almost  always  found  that  patients  had  few  local 
symptoms.  These  appear  to  be  limited  to  lumbar  and  inguinal,  or 
rather  femoral  pain  shooting  down  the  thighs  to  the  knees ;  as  a  rule, 
there  is  no  hypogastric  pain ;  sometimes  there  is  pain  in  coitus  or  for 

1  Op.  cit.,  p.  37. 

2  Op.  cit.,  1st  edition,  p.  119,  omitted  in  4tli  edition. 

'  H.  Bennet,  Op.  cit.,  Appendix,  Uterine  Pathology  in  India,  by  D.   S. 
Stewart,  p.  587. 
*  Op.  cit.,  p.  485. 


ULCERATION   AND    ULCERS    OF    THE    UTERINE    CERVIX      639 

a  daj  or  two  afterwards ;  sometimes  after  sexual  intercourse  there  is  a 
slight  discharge  of  blood  mixed  with  the  leucorrhoea,  and  if  the  ulcer 
is  fungous,  there  may  even  be  haemorrhage,  more  or  less  abundant  but 
always  limited  in  duration.  The  general  symptoms  are  usually  more 
marked.  Without  presenting  anything  very  special,  they  almost  always 
attract  attention  to  the  uterus,  even  when  there  are  no  local  symptoms. 
Amongst  those  which  are  common  to  all  uterine  diseases,  disorders  of  the 
digestive  functions  I  think  occupy  the  first  place  in  cases  of  obstinate 
ulceration.  Patients  almost  always  complain  of  dyspepsia;  they  are 
languid  and  their  suffering  is  increased  by  emaciation,  ansemia,  pale- 
ness, and  the  peculiar  alteration  of  the  features  which  has  been  desig- 
nated by  the  name  oi  fades  uterina.  These  symptoms,  however,  it 
will  be  seen,  merely  attract  attention  to  the  uterus  and  to  the  neces- 
sity of  examination  by  speculum,  which  is  indispensable  in  order  to 
determine  the  existence  and  character  of  the  lesion.  The  objective 
signs  alone  allow  of  a  diagnosis  being  made. 

Objective  signs — I.  Diversity  in  the  form  of  cervical  ulcers. — Cer- 
vical ulceration  is  seldom  deep.  Its  existence  is  manifested  by  the 
condition  of  the  surface  rather  than  by  the  loss  of  substance.  The 
ulcers  which  least  alter  the  aspect,  form  or  structure  of  the  cervical 
mucous  membrane  are  erosions,  exuberations,  fissures.  Next  in 
order  come  ulcerations  proper,  some  of  which  are  distinguished  by  an 
exuberance  of  tissue,  others  by  a  more  or  less  sensible  loss  of  sub- 
stance. In  the  former  category  are  granular,  vegetating,  fungous, 
varicose  ulcers  and  generally  those  depending  on  chronic  metritis, 
uterine  catarrh,  or  merely  on  pregnancy ;  in  the  latter,  excavated 
ulcers,  those  with  greyish  base,  indurated  ulcers,  ulcers  with  callous 
borders  perpendicular  to  the  surface  or  detached  from  it,  corroding 
ulcers  and  generally  those  which  are  kept  up  by  a  diathetic  affection. 

Fissures  are  chiefly  found  where  the  cervix  has  been  lacerated  by 
previous  labours,  and  they  are  situated  at  the  base  of  these  old  lacera- 
tions. Thence  they  may  extend,  forming,  on  a  more  or  less  consider- 
able portion  of  the  cervix,  exuberations  which  have  a  continual 
tendency  to  increase.  When  erosion  of  the  cervix  is  left  to  itself  for 
some  time,  or  exposed  for  several  months  to  the  deleterious  influence 
of  external  causes,  e.g.  want  of  cleanliness,  venereal  excesses,  abor- 
tions, or  repeated  deliveries,  it  becomes  transformed  into  an  ulcera- 
tion, at  first  deep  and  accompanied  by  loss  of  substance,  later  on  filled 
up  by  the  development  of  granulations  produced  either  from  papillary 
hypertrophy,  or  rather  from  true  cicatricial  granulations  which  rise 
from  the  base  and  soon  project  beyond  the  smooth  and  healthy  surface 
of  the  cervix.  The  hypertrophic  tendency  of  these  granulations  is 
sometimes  so  considerable,  that  the  ulcer  may  pass  from  the  granular 
to  the  vegetating  form,  presenting  excrescences  of  from  3  to  5  millime- 
tres in  height  of  dark  red  colour  similar  to  that  of  uterine  granula- 
tions, formed  like  them  and  like  true  granulations  of  a  very  delicate 
and  very  vascular  fibro-plastic  tissue,  often  very  near  together,  separ- 
ated by  hollows,  protruding  more  or  less  over  the  irregular  border  of 
the  ulcer,  sometimes  projecting  into  the  cervical  cavity,  giving  rise  to 


640  UTEEINE   DISEASES    IN    DETAIL 

a  very  abundant  purulent  secretion  requiring  immediate  treatment. 
As  soon  as  discovered  they  should  be  treated  energetically. 

Scanzoni  ^  says  that  varicose  ulceration  is  one  of  the  forms  least 
frequently  seen.  It  is  only  developed  after  a  chronic  stasis  of  blood, 
within  the  uterine  walls.  The  ulceration  is  consecutive  to  congestion 
of  the  organ ;  not  only  is  its  colour  bluish  red,  like  that  of  the 
genital  organs  when  gestation  is  advanced^  but  its  surface  is  traversed 
by  varicose  veins.  "  In  one  case,"  adds  this  writer,  "  such  an  erosion 
was  traversed  by  a  vein  about  half  an  inch  in  length  and  dilated  to  the 
thickness  of  a  crow's  quill,  from  which  there  was  discharged  about  two 
ounces  of  blood  when  we  opened  it." 

The  ulcers  kept  up  by  diathetic  disorders  usually  present  different 
forms.  The  hypertrophic  tendency  of  the  uterine  tissue  may  some- 
times render  them  granular  or  fungous  like  the  preceding ;  but  fre- 
quently, in  place  of  being  exuberant  {excedens)  the  diathetic  ulcer  is 
distinguished  by  loss  of  substance,  by  its  colour,  its  consistency  and 
its  limits.  Thus  the  base,  instead  of  being  granular  and  exuberant,  is 
depressed,  irregular,  more  or  less  hard,  covered  with  a  thick  yellow  or 
greyish  secretion,  which  is  sometimes  adhesive  and  pseudo -membranous, 
at  other  times,  on  the  contrary,  transparent,  ichorous,  sanious  and  san- 
guinolent.  The  borders,  in  place  of  being  irregular,  ill  defined,  and 
concealing  the  limits  of  the  ulcer  more  or  less,  are,  on  the  contrary, 
well  marked,  of  a  bright  red,  contrasting  with  the  base  of  the  ulcer  as 
well  as  with  the  neighbouring  tissues,  following  a  regular  curve,  or 
ragged  and  spreading  unequally  in  various  directions,  now  detached, 
soft  and  pale,  now  adhesive,  perpendicular  and  hard. 

II.  Diversity/  in  the  nature  of  cervical  ulcers. — With  regard  to 
their  nature,  cervical  ulcers  depending  on  disordered  local  vitality, 
whether  physiological  or  pathological,  are  easily  distinguished  from 
ulcers  depending  on  general  diathetic  disorders. 

1.  Amongst  the  former,  depending  on  an  alteration  of  local  vitality, 
one  of  the  most  remarkable  is  the  ulcer  produced  or  kept  up  by  preg- 
nancy.  It  is  difficult  to  know  whether  pregnancy  is  the  only  cause  of 
these  ulcerations.  It  is  probable  that  many  of  them  are  really  due  to 
the  existence  of  some  general  undetermined  aQ"ection  or  to  a  special 
tendency  of  the  uterine  tissue  to  become  ulcerated  as  an  effect  of  the 
special  irritation  or  the  epithelial  maceration  caused  by  the  leucorrhoea 
produced  by  pregnancy.  Pregnancy,  however,  by  congesting  the 
cervix  with  the  rest  of  the  organ,  and  especially  by  softening  it  and 
modifying  its  nutrition,  has  determined  ulceration,  even  if  it  has  not 
predisposed  to  it. 

However  that  may  be,  it  is  all  the  more  important  to  pay  attention 
to  these  ulcerations,  as  they  seem  actually  to  have  produced  abortion 
in  some  cases. 

The  ulcer  produced  or  kept  up  by  uterine  catarrh  is  recognised  by 
the  existence  of  a  concomitant  uterine  leucorrhoea  and  by  the  presence 
in  the  midst  of  the  granulations  of  inflamed  hypertrophied  follicles, 

'  Scanzoni,  op.  cit.,  p.  212. 


ULCERATION    AND    ULCEIiS    OF    THE    UTERINE    CERVIX        641 

producing  an  abundant  hypersecretion.  It  is  usually  granular,  some- 
times even  fungous,  and  except  at  the  commencement,  when  it  is  only 
shghtly  raised  and  has  a  velvety  or  strawberry  aspect,  the  surface 
becomes  irregular  and  broken,  owing  to  the  inequality  in  the  size  of 
the  granulations  ;  the  fluid  pellicle  which  covers  it  is  not  only  purulent, 
but  viscous,  more  or  less  tenacious  and  adherent ;  usually  the  ulcer 
cannot  be  laid  bare  nor  made  to  bleed  without  wiping  it  well.  Never- 
theless we  cannot  cure  the  ulcer  by  merely  curing  the  leucorrhcea ; 
unless  the  means  of  treatment,  such  as  the  introduction  of  nitrate  of 
silver,  be  sufficient  to  modify  profoundly  the  surface  of  the  ulcer  as 
well  as  the  uterine  cavity. 

Ulceration  determined  by  the  persistence  of  chronic  metritis, 
especially  of  parenchymatous  metritis,  whilst  occupying  an  important 
place  in  the  production  of  cervical  ulcers,  is  far  from  being  as  frequent 
as  is  represented  by  modern  gynaecologists  who  describe  cervical  ulce- 
rations as  the  termination  of  metritis.  Sometimes  indeed  their  parts 
seem  to  me  to  be  reversed,  and  especially  in  cases  where  the  metritis 
is  confined  to  the  cervix,  we  may  regard  it  as  being  as  often  the  effect 
as  the  cause  of  ulceration. 

2.  Amongst  ulcers  depending  on  general  diathetic  alterations  we 
may  first  of  all  distinguish  herpetic  ulcers,  which  may  be  recognised  at 
the  outset  by  the  appearance  of  one  of  the  eruptive  forms  which  I  have 
described  as  originating  them ;  later  on,  by  the  formation  on  the  bor- 
ders or  in  the  neighbourhood  of  the  ulcer  of  vesicles,  phlyctenes  and 
pustules  analogous  to  those  from  which  they  sprang.  Scorbutic  ulcers, 
which  occur  but  seldom,  are  violet  in  colour,  fungous,  soft  and  bleed 
easily ;  they  are  also  engorged  and  oedematous  at  the  base  or  at  the 
part  surrounding  the  cervix.  Scrofulous  ulcers  have  their  edges  de- 
tached and  slimy,  often  spreading  considerably  over  both  cervical  lips. 
Like  most  of  the  others,  with  the  single  exception  perhaps  of  leucor- 
rhoeic  ulcers,  they  are  not  confined  to  the  posterior  lip  of  the  cervix, 
and  they  seem  to  be  as  common  on  the  anterior  as  on  the  posterior 
lip.  They  secrete  pus  abundantly,  which  is  often  unhealthy,  serous  or 
sero-caseous.  It  would  seem  as  if  from  their  borders  and  from  the 
anfractuosities  hollowed  out  below  them  there  flowed  a  thick  pus,  con- 
densed by  its  prolonged  sojourn  in  these  crevices  and  from  which 
the  serous  part  has  already  been  discharged.  I  think  it  is  this 
thickened  pus,  mixed  with  fragments  of  tissue  separated  by  the 
progress  of  ulceration,  which  has  sometimes  been  taken  for  tuberculous 
matter. 

Si/philitic  ulcers  are  rare  on  the  cervix  when  compared  with  their 
frequency  on  the  vulva  and  other  parts ;  they  are  not,  however,  rare 
absolutely.  I  have  frequently  seen  chancre  of  the  anterior  lip  deter- 
mine by  contagion,  after  the  lapse  of  a  few  days,  the  appearance  of  a 
chancre  on  the  corresponding  part  of  the  posterior  vaginal  wall  which 
is  constantly  in  contact  with  this  portion  of  the  anterior  lip  and  on  no 
other  part.  I  have  seen  women  who  were  accused  of  having  infected 
men  with  whom  they  had  had  intercourse,  and  in  whom  I  could  not 

41 


642  UTERINE   DISEASES  IN   DETAIL 

discover  any  ulcerated  or  chancrous  surface,  any  syphilitic  symptom 
or  even  any  morbid  symptom,  with  the  exception  of  a  leucorrhoeic 
drop  escaping  at  intervals  from  the  os  uteri. 

After  a  few  days  I  have  seen  the  circumference  of  this  orifice 
gradually  attacked  from  within  outwards  by  a  chancrous  ulceration 
commencing  evidently  in  the  cervical  cavity  and  gradually  extending 
to  one  of  the  lips ;  I  have  collected  six  well-authenticated  cases  of  this 
development  of  iutra-cervico-uterine  chancre.  Chancres  of  the  cervix 
have  the  same  appearance  that  they  present  on  other  parts  of  the 
genital  mucous  membrane ;  they  are  seldom  indurated ;  they  have 
perpendicular  edges,  on  a  greyish  base,  are  sometimes  diphtheritic,  or 
at  least  covered  with  a  thick,  hard,  adhesive  pseudo-membrane,  and 
have  apparently  a  phagedenic  tendency.  Lastly,  the  cancerous  ulcer, 
variable  in  form  with  edges  usually  hard,  unequal,  friable  and 
bleeding,  with  an  ichorous  rather  than  a  muco-purulent  secretion, 
presents  characteristics  so  well  marked  that  I  cannot  dwell  on 
them  here ;  they  will  be  described  when  we  come  to  Cancer  of  the 
Uterus. 

III.  Diversity  of  the  ulcerative  or  destructive  tendency  of  ulcers  of  the 
Cervix. — Superficial  ulcers,  slightly  granular  exulcerations,  erosions  pro- 
duced by  the  various  eruptions  previously  described,  have  frequently  a 
natural  tendency  towards  cicatrisation  and  may  be  called  non-malignant. 
Simple  granular  or  even  fungous  ulcers,  those  due  to  pregnancy,  leu- 
corrhcBa  or  chronic  metritis,  frequently  also  diathetic  ulcers,  although 
not  naturally  tending  towards  cicatrisation  but  on  the  contrary  to 
further  development,  may  also  be  ranked  as  non-malignant  because 
prompt  and  energetic  rational  treatment  succeeds  in  curing  them. 
There  are,  however,  ulcers  which,  on  the  contrary,  have  a  destructive, 
fatal  tendency,  and  which  may  be  characterised  as  malignant.  Can- 
cerous abscess  may  be  placed  in  the  front  rank ;  they  are  easily  distin- 
guished from  others.  Are  these  the  ulcers  described  by  Clarke  and 
Levers  as  the  conoding  ulcer  of  the  os  uteri?  I  am  inclined  to  think 
with  Kiwisch  and  Scanzoni^  that  it  is  so;  Jlokitansky,^  however,  de- 
scribes a  corroding  ulcer  of  the  uterine  orifice  which  is  similar  to  the 
phagedenic  ulcer  of  the  skin.  "Although  it  has  no  neoplasm  for  a 
starting  point,"  he  says,  "  yet  it  gradually  destroys  the  vaginal  portion 
or  even  the  greater  part  of  the  uterus,  destroying  at  the  same  time  the 
adjacent  tissues  as  far  as  the  rectum  and  bladder.  It  is  an  irregular 
ulcer  with  sinuous,  indented  outline,  at  the  borders  and  base  of  which, 
from  slow  inflammation,  the  tissues  are  thickened,  hypertrophied  and 
hardened.  The  base  is  of  a  dirty  green  or  brownish-green  colour, 
secreting  sometimes  a  small  quantity  of  a  viscous  purulent  fluid,  at 
other  times  a  more  abundant  and  aqueous  fluid ;  it  presents  no  granu- 
lations, but  a  gelatinous  exudation,  in  which  the  various  tissues  of  the 
ulcerated  surface  hquefy.''^  This  description  evidently  refers,  if  not  to 
encephaloid  or  scirrhous  cancer,  at  least  to  epithelioma  of  the  cervix, 
and  these  ulcers  may  produce  considerable  destruction  of  the  uterus. 

'  Op.  cit.,  p.  214. 

2  ^^a^.  imtli.,  1861,  t.  iii,  p.  538. 


ULCERATION    AND    ULCERS    OF    THE    UTERINE    CERVIX       643 

I  have  seen  several  cases  of  the  kind,  and  they  may  be  found  in  the 
admirable  works  of  Cruveilhier  and  Lebert.  But  apart  from  this  ten- 
dency, which  is  due  to  a  diathetic  affection,  may  not  a  similar  tendency 
be  developed  in  a  cervical  ulcer,  especially  if  syphilitic  ?  I  have  seen 
one  case  so  marked  that  I  think  the  cervix  would  have  been  destroyed 
if  I  had  not  arrested  the  progress  of  the  ulcer  by  repeated  cauterisa- 
tions and  frequent  dressings.  I  willingly  reserve  the  name  of  corroding 
or  phagedenic  to  this  form  of  ulceration. 

At  other  times  without  having  so  marked  a  destructive  tendency, 
the  ulceration  pursues  its  course  in  one  direction  whilst  cicatrisation 
is  obtained  in  the  other,  and  its  existence  is  thus  prolonged  indefi- 
nitely. In  such  cases  the  ulcer  may  be  called  serpiginoiis,  and  should 
be  carefully  and  energetically  treated. 

But  a  well-marked  destructive  tendency  is  manifested  in  the  ulcer 
when  it  becomes  diphtheritic.  Fortunately  this  case  is  very  rare,  and 
judging  from  the  description  which  Boys  de  Loury  and  Costilhes^ 
give  of  it  they  do  not  seem  to  have  observed  it  accurately.  I  think  I 
have  seen  it  as  well  as  the  phagedenic  ulcer  once.  However,  even 
when  not  truly  diphtheritic,  cervical  ulcers  may  frequently  be  covered 
with  pseudo-membranes  of  variable  nature,  like  those  on  the  tonsils, 
in  the  mouth  and  on  the  pharynx.  I  share  the  opinion^  of  Laboulbene 
and  other  practitioners  who  have  studied  diphtheritic  and  pseudo- 
membranous products,  that  there  are  great  differences  in  the  nature 
and  degree  of  maladies  presenting  this  complication.  I  am  convinced 
from  frequent  observation  that  cervical  ulcers  are  also  liable  to  be 
covered  with  membranous,  pseudo-membranous  and  even  diphtheritic 
])roducts  from  the  effects  of  an  adynamic  and  cachectic  condition. 
Without  having  the  extreme  gravity  of  true  diphtheria,  especially 
when  left  to  itself,  these  products  always  indicate  an  unfavorable  ten- 
dency and  necessitate  active  and  energetic  treatment.  They  may  be 
distinguished  by  the  difficulty  there  is  m  getting  rid  of  the  yellowish 
or  greenish  layer  covering  the  ulcer.  The  membrane  has  to  be  taken 
away  in  fragments  with  forceps  before  the  base  of  the  hollow  bleeding 
ulcer  is  seen,  which  has  extended  in  breadth  as  well  as  in  depth  under 
the  shelter  of  this  false  membrane.  The  neighbouring  parts  are 
tumefied,  violet  red,  sometimes  livid  and  the  neighbouring  ganglia 
inflamed. 

Treatment. — Granular  ulcerations  of  the  cervix  are  never  cured 
spontaneously,  and  they  have  a  continual  tendency  to  extend  and  to 
become  fungous  when  left  to  themselves ;  therefore  they  should  be 
treated,  care  being  taken  to  fulfil  the  indications  in  the  order  in  which 
they  present  themselves. 

1.  The  first  indication  is  to  treat  the  general  or  local  cause  which 
produces  the  ulcer,  or  which  keeps  it  up.  The  patient  should  follow 
an  antidiathetic  treatment,  the  means  of  which  will  vary,  not  only 
according  to  the  nature  of  the  affection  on  which  the  ulcer  depends, 

'  Gazette  medicale  de  Paris,  1845,  p.  374. 

'  Recherches  sur  les  conditions  mctcorologiques  dti  developpentaU  du croup 
et  de  la  diphtherie,  p.  35.  Montpellier,  1862. 


614  UTBEINE    DISEASES    IN    DETAIL 

but  also  according  to  the  condition  of  the  various  functions ;  for  the 
form  in  which  the  remedy  is  administered  must  vary  according  to 
whether  the  condition  of  the  digestive  functions  is  normal  or  not.  As 
to  the  local  state,  we  must  not  forget  that  fluxion,  congestion, 
inflammation,  hypertrophy  or  leucorrhcea  may  complicate  the  ulcer 
as  cause,  effect  or  simple  coincidence.  But  whatever  part  these 
morbid  states  may  play,  they  should  be  treated  by  bloodletting, 
rest,  baths,  prolonged  irrigations,  associated  with  general  and  local 
resolvents. 

2.  The  second  indication  is  to  maintain  great  cleanliness  of  the 
ulcer  and  neighbouring  tissues,  sometimes  isolating  the  ulcer  from 
the  contiguous  surfaces.  The  necessary  attentions  to  cleanliness  con- 
sist in  irrigations  with  tepid  water  repeated  at  least  twice  a  day  in 
order  to  prevent  the  fluids  which  are  secreted  from  remaining  in  the 
vagina ;  sometimes  they  require  to  be  made  every  four  hours.  These 
sometimes  suf&ce  for  the  cure  of  erosions  and  exulcerations.  They 
serve  two  purposes  :  by  ridding  the  vagina  of  the  abundant  and  irri- 
tating secretions  which  accumulate  there,  they  prevent  the  contact  of 
these  fluids  from  keeping  up  and  increasing  the  ulceration ;  by  clean- 
ing the  ulcer  itself,  which  is  irritated  and  positively  infected  by  its 
own  secretion,  they  prevent  its  extension  and  also  the  transmission  by 
contagion  of  the  malady  to  the  contiguous  mucous  surfaces.  As  a 
rule,  simple  irrigations  should  be  made  with  tepid  water  in  winter  and 
at  the  temperature  of  the  room  in  summer.  Cold  water  should  be 
used  when  the  ulcer  is  fungous  or  bleeding.  These  irrigations  may 
be  rendered  disinfecting  by  the  addition  of  a  little  carbolic  acid,  vine- 
gar, permanganate  of  iron  or  chloride  of  lime.  When  there  is  conges- 
tion or  a  tendency  to  hsemorrhage  I  prescribe  injections  to  be  made 
three  times  a  day  with  water  as  hot  as  can  be  borne  (112°  E.)  with 
one  or  two  tablespoonfuls  of  a  solution  of  carbolic  acid  (75  gr.  crys- 
tallised carbolic  acid  to  a  quart  of  water).  These  injections  often 
sufiice  to  cure  certain  kinds  of  ulcers. 

3.  The  third  indication  is  to  modify  the  surface  of  the  ulcer  in 
such  a  way  as  to  stimulate  its  vitality  and  to  produce  a  tendency 
towards  cicatrisation,  a  more  or  less  marked  resolvent  action.  A 
tampon  applied  every  day  to  the  cleansed  cervix  for  a  few  hours  is 
sometimes  sufficient  to  give  a  favorable  impulse  to  cicatrisation.  At 
other  times  an  inert  powder,  such  as  starch,  will  produce  the  same 
effect ;  in  both  cases  unless  there  is  no  discharge  the  vagina  should  be 
syringed  several  times  a  day.  The  injections  may  be  medicated,  but 
previously  to  using  them  a  simple  or  purely  detersive  lotion  should  be 
made. 

After  having  washed  and  wiped  the  cervix  we  may  apply  a  little 
subnitrate  of  bismuth,  calomel,  alum,  sulphate  of  zinc  or  acetate  of 
lead  to  the  ulcer,  and  then  a  spoonful  of  starch  in  powder  to  keep  the 
drug  in  place,  or  a  tampon  will  do  as  well.  I  generally  place  the 
powder  on  the  tampon  and  then  apply  it  to  the  cervix,  pushing  it  close 
against  the  uterus  while  I  withdraw  the  speculum,  taking  care  not  to 
allow  the  powder  or  fluid  to  come  in  contact  with  the  vaginal  wall.    A 


ULCERATION    AND    ULCERS    OF    THE    UTERINE    CERVIX       645 

number  of  drugs  are  employed  in  this  way.  I  shall  content  myself 
with  mentioning  alum,  tannin,  sulphate  of  zinc,  sulphate  of  copper, 
nitrate  of  silver,  tincture  of  iodine,  perchloride  of  iron.  Each  of  these 
medicaments  may  answer  to  a  special  indication,  which  may  be  gra- 
duated according  to  the  nature  of  the  lesions.  Thus  it  is  sufficient  to 
touch  simple  erosions  with  a  weak  solution  of  alum  or  nitrate  of  silver. 
When  the  ulceration  is  more  extensive  or  deeper,  these  solutions  may 
be  made  stronger,  and  when  there  is  leucorrhoea  or  excoriation  of  the 
vaginal  cids-de-sac,  as  frequently  happens,  these  drugs  should  be  left 
for  a  few  seconds  in  contact  with  the  diseased  surfaces  in  order  to  give 
them  time  to  penetrate  sufficiently.  After  having  embraced  the  cervix 
with  a  wooden,  porcelain,  or  glass  speculum,  and  having  wiped  not 
only  the  whole  surface  of  this  organ,  but  the  neighbouring  portion  of 
the  vagina,  we  pour  into  the  inclined  speculum  one  or  two  teaspoou- 
fuls  of  a  solution  of  nitrate  of  silver  (30,  20  or  10  per  cent,  according 
to  whether  we  wish  to  use  it  as  an  alterative,  a  catheretic,  or  a  mild 
caustic).  It  is  left  for  a  few  seconds  in  contact  with  the  diseased 
surfaces,  then  poured  out  of  the  speculum  by  depressing  the  instru- 
ment, what  is  left  being  removed  with  a  little  cotton  wool  to  prevent 
any  injury  to  the  vagina  or  vulva.  When  only  the  surface  of  the  ulcer 
requires  treatment  we  simply  touch  it  with  the  crayon,  perchloride  of 
iron  or  laudanum.  These  are  the  agents  I  use  most  frequently  and 
find  successful.  When  the  neck  is  engorged,  (Edematous,  or  when  the 
ulcer  is  callous,  the  tincture  of  iodine  has  the  advantage  of  being 
resolvent  as  well  as  catheretic.  When  the  ulcer  is  fungous,  varicose, 
bleeding,  the  perchloride  of  iron  (30  per  cent.),  which  acts  not  only  as 
a  caustic  but  as  a  powerful  hemostatic,  is  of  great  use.  In  such  cases 
I  sometimes  touch  the  ulcer  with  iodoform,  creosote  or  crystallised 
chromic  acid ;  but  these  medicaments  should  be  reserved  for  cases  in 
which  destructive  action  is  desirable.  When  a  specific  action  is 
required  solutions  of  corrosive  sublimate  should  be  used. 

We  may  also  have  recourse  to  ointments,  though  I  think  they  are 
less  efficacious  than  other  applications.  If  there  is  pain  and  hyperses- 
thesia  I  use  laudanum,  as  recommended  by  Aran,  only  instead  of 
keeping  it  in  place  by  powdered  starch,  after  pouring  in  from  15  to 
60  drops  I  introduce  a  tampon,  which  I  push  against  the  cervix,  which 
the  patient  removes  a  few  hours  afterwards  in  order  to  make  an  injec- 
tion. In  other  cases  I  spread  a  thick  layer  of  opiate  ointment  on  the 
tampon  and  apply  it  to  the  ulcer.  When  I  wish  to  excite  a  resolvent 
action  I  apply  in  the  same  way  an  ointment  of  iodide  of  lead  and 
potassium  or  a  glycerole  of  bromide  or  iodide  of  potassium.  If  specific 
action  is  needed  as  well  I  use  mercurial  and  belladonna  ointment,  or 
ointment  of  red  oxide  of  mercury,  which  is  extremely  resolvent,  and  in 
some  cases  hastens  cicatrisation.  In  cases  of  acne  or  of  ulcer  kept  up 
by  folliculitis  I  apply  an  ointment  of  the  double  iodide  and  chloride  of 
mercury,  taking  care  to  protect  the  vaginal  walls,  and  I  treat  acne 
rosacea  of  the  cervix  like  that  of  the  face. 

Medicated  pessaries  are  not  so  good,  having  the  double  drawback 
of  not  being  always  pushed  as  far  as  the  cervix  or  of  not  remaining 


646  UTEEINE    DISEASES   IN    DETAIL 

there,  and  of  acting  on  the  vaginal  mucous  membrane  as  well  as  on 
the  uterus. 

4.  The  fourth  indication  is  to  destroy  by  cauterisation  granula- 
tions, fungosities,  callosities,  in  fact  all  pathological  tissues."  The 
sulphate  of  copper  and  the  nitrate  of  silver  are  quite  insufficient  for 
this  purpose,  being  only  applicable  to  small  ulcers,  and  only  curing 
after  a  considerable  number  of  cauterisations,  and  modifying  the  tissue 
so  slightly  that  whilst  they  favour  dessication  of  the  ulcer  and  repro- 
duction of  the  epithelial  covering  of  its  surface,  they  leave  the  deeper 
alterations  untouched,  or  may  even  increase  them  by  the  repeated 
irritation  which  their  too  frequent  contact  determines  in  the  tissue. 
What  I  have  just  said  of  nitrate  of  silver  may  also  be  said  of  more 
energetic  caustics,  especially  of  the  various  acids,  and  in  particular  of 
the  acid  nitrate  of  mercury  so  much  used  at  present.  Their  liquid 
form  is  also  a  drawback ;  in  the  case  of  the  acid  nitrate  of  mercury 
there  is  the  additional  risk  of  salivation.  The  potential  cautery,  such 
as  Vienna  paste,  is  preferable  to  the  means  just  enumerated,  and  would 
be  indispensable  in  cases  in  which  the  size  of  the  granulations  necessi- 
tates deep  destruction,  were  not  the  same  effect  produced  with  less 
danger  with  the  actual  cautery.  Actual  cauterisation  may  be  either 
superficial  or  deep  as  required.  It  should  be  sufficiently  energetic  not 
to  make  a  second  application  necessary,  remembering  that  the  depth  of 
the  scar  produced  is  really  less  than  it  seems  to  be.  In  such  cases  we 
must  not  fear  to  use  more  than  one  cautery  to  the  portion  of  the  cervix 
to  be  destroyed,  especially  if  the  fungosities  of  the  ulcer  are  voluminous 
and  bleeding,  if  the  cervix  is  engorged  and  hypertrophied,  if  we  require, 
in  short,  by  suppurative  action  of  some  duration  and  by  the  cicatricial 
process  which  follows  to  produce  absorption  of  the  tissues  or  inter- 
stitial fluids  and  resolution  of  the  tumour  formed  by  the  ulcerated 
cervix.  I  have  seen  ulcers  of  this  kind  resist  cicatrisation  so  long  as 
to  force  me  to  have  recourse  to  the  actual  cautery  every  four  or  five 
weeks  during  general  and  local  treatment;  but  I  have  never  had  a  case 
that  I  could  not  cure.  Actual  cauterisation  is  also  applicable  to  ulcers 
during  pregnancy;  double  care,  however,  is  required  to  prevent  any 
subsequent  fluxionary  movement  towards  the  uterus.  When  rest, 
baths  and  cold  fomentations  are  insufficient  the  best  means  of  avoiding 
abortion  is  to  subdue  sanguineous  fluxion  of  the  uterus  by  revulsive 
bleedings  of  the  arm,  which  may  be  repeated  when  necessary,  but 
should  not  be  copious. 

Lastly,  we  must  not  imagine  that  all  local  treatment  is  finished  when 
we  have  burned  the  ulcer.  As  soon  as  elimination  of  the  scar  com- 
mences the  physician  should  direct  the  cicatricial  tendencies  of  the 
bleeding  surface.  In  many  cases  this  period  is  critical,  and  if  a  favor- 
able impulse  is  not  given  to  the  cure  of  this  new  wound  it  may  relapse 
under  the  unfavorable  influence  which  kept  up  the  ulcer,  and  in  a  (ew 
days  become  as  fungous  as  before  owing  to  the  hypertrophic  tendencies 
of  the  uterine  tissue.  The  wound  should  therefore  be  stimulated  to 
form  a  good  cicatrix  in  a  few  days.  Lastly,  we  must  be  wilhng  to  wait 
for  a  considerable  time  after  cauterisation  before   obtaining   all   the 


TJLCEEATION    AND    ULCERS   OP    THE    UTEEINE    CERVIX      647 

results  that  we  have  a  right  to  expect  from  itj  and  we  should  use  the 
general  and  local  means  of  which  I  have  so  often  spoken  (especially 
hydropathy  and  mineral  waters)  to  forward  resolution  and  to  prevent 
the  renewal  of  ulceration  or  the  development  of  some  other  affection 
on  an  organ  too  recently  cured  not  to  be  liable  to  a  relapse. 


CHAPTEE  lY 

OEGANIC   ALTEEATIOXS — FIBEOUS   TUIIOTES — POLYPI   A^'D   MOLES — TrBEECLE — 

CAXCEE 

Organic  alterations  differ  from  morbid  states  without  neoplasm  in 
the  production  of  new  elements  appearing  in  the  form  of  more  or  less 
voluminous  tumours^  and  constituting  the  most  important  character  of 
these  diseases  as  regards  diagnosis  and  treatment.  These  new 
elements  may  be  the  very  elements  of  the  uterine  tissue  or  their 
analogues  (homeomorphous  tumours),  or  they  may  appear  to  have  only 
a  distant  analogy  with  these  elements  and  be  developed  in  the  uterus 
with  the  same  characters  which  distinguish  them  in  the  parenchyma  of 
any  other  organ  (heteromorphous  tumours).  To  the  first  category 
hAong  fibroids,  fibromata^  myomata  and  polypi ;  to  the  second  tubercle 
and  cancer. 

PiBROus  Tumours 

The  names  fibrous  tumours,  fibrous  bodies,  myomata,  leio-myomata, 
fibroids,  hysteromata,  &c.,  are  used  to  designate  tumours  of  a  fibrous 
appearance  which  are  frequently  developed  in  the  uterine  parenchyma. 
They  are  excrescences  from  the  uterine  walls  similar  in  structure  to  the 
uterine  tissue.  They  are  also  the  most  common  of  all  organic  diseases 
of  the  womb. 

The  name  fibrous  body  given  by  Cruveilhier  indicates  the  nature,  the 
isolation  and  the  independence  of  these  productions,  as  well  as  the 
absence  of  pediculisation  which  distinguishes  them  from  polypi. 

The  expression  interstitial  filrous  tumours  is  often  employed  to  call 
attention  to  their  development  in  the  midst  of  the  uterine  tissue.  The 
recent  names  of  fibroids  ^  and  fibromata  designate  the  principal  aspects 
under  which  they  are  usually  seen;  that  of  myomata"  defines  their 
muscular  or  fleshy  texture ;  whilst  that  of  hysteromata  (Broca)  recalls 
their  nature,  which  is  no  other  than  that  of  the  uterus  itself,  their 
development  appearing  to  be  due,  according  to  my  own  observations 
as  well  as  that  of  Lebert  and  Eobin,  to  hypertrophy  of  the  fibro- 
muscular  element,  of  all  the  anatomical  elements  that  which  best 
characterises  the  uterine  tissue.  They  are  rounded  tumours,  slightly 
irregular  or  nodulated  on  the  surface,  formed  of  greyish  fibres  or 
fibrillse  of  considerable  consistency,  closely  approximated,  encircling  a 
fictitious  centre,  or  it  may  be  several  centres  closely  interlaced,  inter- 
sected with  dull  white  bands,  distinct  from  the  uterine  wall  in  colour, 

^  M.  H.  Currey,  On  Fibroids  of  the  Uterus  {Philadelphia  Med.  and  Surg. 
Bepoi-t,  March,  1874). 

^  Virchow,  Die  Kranlchaften  Geschwillste.  Berlin,  1863.  He  calls  them 
leio-myomata,  or  tumours  formed  of  smooth  muscular  fibres. 


FIBROUS   TUMOURS 


649 


consistency  and  in  the  absence  of  blood-vessels  of  any  size. — They 
occur  at  all  ages^  before  20  and  after  80.^ 

The  site  is  in  relation  with  the  thickness  of  the  uterine  wall  and  the 
region  of  the  uterus  that  they  occupy. 

1.  As  regards  the  wall,  they  may  be  developed  in  the  central  por- 
tion, in  which  case  they  remain  sessile  for  a  long  time;  or  towards  the 
free  surfaces,  in  which  case  they  are  generally  pediculated.  The  first 
class  are  interstitial.  Those  of  the  second  class  have  been  called  sub- 
mucous or  sub-peritoneal,  according  to  whether  they  push  before  thf  m 
in  the  direction  of  least  resistance  the  mucous  membrane  or  the 
peritoneum ;  but  these  expressions  are  incorrect,  for  the  fact  which  they 
seem  to  imply  does  not  occur :  whether  covered  with  uterine  mucous 
membrane  or  peritoneum  fibromata  have  always  a  thin  layer  of  uterine 
tissue  over  them.^     Even  the  interstitial  tumours  may  become  enor- 


FiG.  358. — Interstitial  fibroid  {ad  nat.,  Farre). 

mous  without  being  pediculated,  although  they  are  only  separated  from 
the  uterine  cavity  by  a  thin  layer  of  tissue  proper.  The  uterus  neces- 
sarily participates  in  this  development,  as  if  it  contained  a  product  of 
conception,  a  fact  which  to  some  extent  justifies  the  expression  of 
fibrous  pregnancy''^  given  to  it. 

2.  As  regards  the  region  of  the  uterus,  fibromata  may  arise  from 
any  point ;  they  are,  however,  produced  more  frequently  in  the  body 
than  in  the  cervix,  almost  in  the  proportion  of  110  to  21.*  The  latter 
segment  may  remain  intact,  whilst  the  body  is  loaded  with  them  so 
as  to  resemble  a  bag  filled  with  nuts.^ 

1  Engehnann  {Zeitschrift  f.  Geburtsk,  1877,  Bd.  i,  Heft  1.) 

^  Cruveilhier,  Anatomic  pathologique,  t.  iii,  p.  067.  Paris,  1865.  Baylc, 
Diet,  des  sciences  medicales,  vii,  72.  Paris,  1813. 

^  P.  Guyon,  Des  tumeurs  fibreuses  do  L'uterus,  p.  13.  Paris,  1860. 

*  Safford  Lee,  On  Tumours  of  the  Utcnts.  London,  1817. 

^  As  in  an  anatomical  preparation  of  Huguier's,  quoted  by  Guyon,  op.  fit., 
p.  15. 


650 


UTERINE    DISEASES    IN    DETAIL 


In  fibromata  of  the  body  those  of  the  posterior  wall  are  the  most 
frequent^  those  of  the  anterior  wall  come  next,  and  those  of  the  fundus 
last.i  Those  of  the  cervix  are  developed  like  the  latter,  and  are 
usually  pediculated  towards  the  cervical  cavity ;  they  escape  from  the 
uterine  orifice  much  more  easily  than  do  those  of  the  body. 

The  size  of  uterine  fibroids  varies  greatly,  according  to  the  stage  of 
development  and  the  arrest  which  the  development  may  undergo ;  they 
may  be  seen  from  the  size  of  a  pin's  head  to  that  of  the  head  of  an 


Fig.   359. — Fibroid    tumour  of    enormous   size,  rising  to  the  hypochondriac 
region  (Graily  Hewitt,  op.  cit.,  p.  498,  fig.  102). 

adult.  I  have  seen  a  patient  who  had  one  which  could  not  have 
weighed  less  than  50  Ibs.^  Binz^  examined  one  which  weighed  62  lbs.; 
Walter  one  of  74  lbs.  It  is  the  same  as  regards  number ;  they  may 
be  single  or  multiple.  In  the  latter  case  they  are  usually  of  various 
sizes,  and  they  may  also  be  found  in  the  annexes.*  They  do  not  occur 
singly  as  often  as  Cruveilhier  thinks. 

Sub-peritoneal  fibromata  are  sometimes  very  numerous,  while  the 
sub-mucous  are  usually  single,  probably  from  want  of  room,  for  abla- 
tion is  commonly  followed  by  the  development  of  a  fresh  tumour. 

Interstitial  tumours  are  sometimes  multiple,  one  of  them  generally 

1  Houel,  Manuel  d' anatoinie  pathologique,  p.  596. 

^  Courty,  Excursion  chirurgicale  en  Angleterre,  p.  58.  Montpellier,  1863. 

'  Gazette  med.  de  Paris,  1858,  p.  807. 

■•  Neugehauer  {Prager  Vierteljahrschrift,  Bd.  ii,  S.  59,  1877). 


FIBROUS    TUMOURS  651 

being  larger  than  the  others.  Lastly,  we  may  observe  fibromata 
belonging  to  all  these  three  categories  in  the  same  uterus. 

The/bnw  is  usually  spherical ;  it  may,  however,  assume  various  and 
curious  shapes,  e.g.  pointed,  bilobed,  owing  to  the  entrance  of  the 
tumour  into  the  neck,  or  irregularly  nodulated  when  a  number  of 
tumours  are  fused  together. 

The  texttire  is  very  dense;  the  dull  white  or  mother-of-pearl  tissue 
is  one  of  the  most  resisting  that  is  known.  The  tumour  is  chiefly 
composed  of  amorphous  matter  finely  granulated,  fibrous  or  fibro- 
plastic elements  and  muscular  elements,  or  smooth  muscular  fibre-cells 
which  are  larger  than  in  the  empty  uterus  but  smaller  than  in  preg- 
nancy,^ and  which  form  a  quarter  or  a  half  of  the  mass  of  the  tumour. 
This  composition,  however,  may  vary  according  to  the  starting  point 
of  the  hyperplasia  and  the  predominance  of  any  particular  element : 
hence  fibromata  properly  so-called,  fibroids  (in  which  the  embryonic 
element  predominates),  fibro-myomata,  or  hard  myomata  (the  most 
common),  soft  myomata  (in  which  the  muscular  fibres  and  sometimes 
the  vessels  predominate,  the  connective  tissue  being  thin  and  loose), 
vascular  or  telangiectatic  myomata,  cystic  myomata,  myo-sarcomata,^ 
&c. 

Evolution. — We  must  distinguish  in  fibromata  a  primary  state  of 
development  and  a  secondary  state  in  which  they  live  their  own  life. 

a.  Owing  to  our  ignorance  as  to  the  commencement  of  the  evil 
(from  knowing  only  large  tumours),  it  was  believed  that  there  was  a 
want  of  primordial  continuity  between  the  myoma  and  the  uterine 
tissue  (Bayle,  Cruveilhier).  But  after  histological  researches  had 
proved  the  identity  of  the  fibres  of  the  myoma  proper  with  the 
muscles  of  the  uterus,^  these  tumours,  which  at  first  were  thought  to 
be  developed  in  an  interposed  blastema  were  then  regarded  as  result- 
ing from  local  hypertrophy,^  and  at  a  later  period  as  being  all  special 
hypertrophic  forms  of  the  uterine  parenchyma.^  This  connection  is  so 
close  that  sometimes  it  is  impossible  to  limit  even  large  tumours, 
especially  if  they  are  soft.  Fibromata  therefore  seldom  appear  to  be 
formed  by  the  interstitial  development  of  elements  similar  to  those  in 
the  midst  of  which  the  fibro-plastic  tissue  is  produced  or  their  forma- 
tive blastema  deposited,  but  more  frequently  by  the  proliferation  of  a 
limited  group  of  uterine  fibres,  which  become  isolated  from  all  the 
others  just  as  adenoid  tumours  are  developed  in  the  glands,  heter- 
adenomata  in  their  neighbourhood,  pigment  in  the  choroid,^  &c. 

'  Vogel,  Erlautenmgstafeln  zilr  pathologischen  Histologie.  Leipsic,  1843. — 
Oldham,  Guy's  Hospital  Reports,  1844. — Lebert,  Societe  de  biologie,  1852, 
p.  68.  Anat.  pathol.  gen.,  pi.  157,  32«  liv.,  1859. — Eobin,  These  de  Ferrier, 
1854,  p.  41. 

*  Virchow,  Die  JcranTchaften  Geschwiilste.  Berlin,  1863,  Bd.  iii,  S.  810,  et  seq. 
'  Vogel,  Icones  histol.  pathol.  Leipsic,  1843. 

^  Simpson,  Obstetric.  Mem.  Edinburgh,  1855,  vol.  i,  p.  115. 

*  Virchow,  Wiener  med.  Wochenschrift,  1856,  No.  7. 

®  An  example  of  the  law  of  homology  or  analogy  of  formation. — Vogel, 
Anat.  path,  gen.,  p.  100.  Paris,  1847.— Courty,  Substitutions  organiques,  p.  33. 
Paris,  1847,  and  Gazette  med.  de  Paris,  1847. 


652 


UTERINE    DISEASES    IN    DETAIL 


Their  origin  seems  to  be  a  swelling  of  certain  bundles  of  muscular 
fibres  at  a  given  point  analogous  to  the  tumefaction  of  nerves  in 
neuroma, 

h.  The  life  of  fibromata  may  be  said  to  be  a  parasitic  one  as 
soon  as  they  are  isolated  from  the  tissue  from  which  they  have  taken 
birth.  The  anatomical  independence  which  they  then  acquire  as 
regards  the  uterine  fibres,  the  feeble  vascularity  which  they  enjoy, 
the  capillarity  of  the  vessels  by  which  their  periphery  commu- 
nicates with  the  rest  of  the  womb,  all  concur  to  prove  their  physiolo- 
gical independence.  It  is  easily  ascertained  that,  with  the  exception 
of  some  adhesions  abnormally  established,  they  have  no  continuity 
with  the  tissue  of  the  womb,  but  are  separated  from  it  by  a  loose  cel- 
lular tissue  as  if  by  a  cyst,  sometimes  by  accidental  serous  bursse.^ 
Sometimes  even  the  nutrition  of  fibromata  takes  place  by  imbibition ; 
it  is  probable  that  it  is  so  when  they  seem  to  be  contained  in  an 
envelope  or  a  kind  of  sac  which  isolates  them  in  every  direction ;  it 
cannot  be  otherwise  when  they  are  perfectly  free  in  the  abdomen  with- 


FiG.  360. — Large  fibrous  interstitial  tumour  of  the  uterus,  making  the  size  of 
this  organ  equal  to  that  which  it  acquires  at  full  term  (Sims). 

out  on  that  account  experiencing  any  alteration,  and  even  without 
ceasing  to  grow,  which  is  accounted  for  by  their  being  protected  from 
contact  with  the  air  and  from  the  obscurity  of  their  life.  The  growth 
of  fibromata  is  unlimited  ;  it  is  very  variable  according  to  whether 
their  development  is  rapid,  slow,  stationary  or  even  retrograde.  It  is 
not  rare  to  meet  with  an  interstitial  fibroma  the  size  of  which  is  equal 
to  that  of  a  foetus  of  seven  or  even  nine  months.  Occasionally  they 
are  seen  still  larger  (see  p.  650,  and  Pigs.  359  and  360). 

Amongst  the  alterations  which  they  may  undergo  the  most  uncommon 
is  atrophy  by  retrograde  evolution.  Soft  myomata  may  become  in- 
durated in  consequence  of  inflammation ;  their  muscular  fibres  disap- 

^  Verneuil,  Fenerly  ;  Bulletin  de  la  Societe  anatomique,  xxxix,  346. 


FIBROUS    TUMODES  658 

pear,  they  become  fibrous  and  may  even  assume  a  cartilaginous  aspect. 
The  density  of  the  tumour  increases  much  more  when  the  fibres  com- 
posing it  become  encrusted  with  calcareous  matter  and  when  the  fibroid 
undergoes  petrification.  This  petrification,  to  which  the  name  of  ossi- 
fication has  been  given,  may  occur  in  two  ways,  either  by  a  simple 
])eripheric  encrustation  forming  a  kind  of  shelP  for  the  fibroma,  or  more 
frequently  by  a  general  calcareous  infiltration,  by  the  formation  of 
multiple  concretions  in  the  interior  of  the  tumour,"  and  the  petrifica- 
tion of  the  whole  of  the  fibrous  body.  The  stony  hardness  of  the 
whole  mass  may  be  great  enough  to  allow  of  its  being  polished,  as  was 
done  with  one  in  the  Middlesex  Hospital  Museum.  The  uterus  some- 
times contains  such  stones  of  considerable  size  and  enormous  weight. 
I  have  seen  one  that  weighed  22lbs.  Arnott^  mentions  another  of 
50lbs.  weight,  which  caused  death  in  an  old  woman  by  tearing  the  in- 
testine in  a  fall.  Cruveilhier  regards  the  petrification  of  fibrous  bodies 
as  a  kind  of  atrophy,  an  opinion  which  seems  shared  by  Louis,'*  who 
says  that  the  calcareous  transformations  of  fibromata  occur  chiefly 
after  the  menopause. — Another  kind  of  atrophy  is  the  regressive  fatty 
transformation  of  the  muscular  fibres,  which  modifies  in  an  opposite 
manner  the  consistency  of  fibrous  tumours,  softening  them,  and  giving 
them  a  yellowish  coloration  and  determining  their  partial  liquefaction 
and  the  formation  of  cavities.  This  transformation  (which  bears  some 
analogy  to  the  retrograde  evolution  which  brings  back  the  uterine 
fibres  from  the  state  of  pregnancy  to  that  of  vacuity)  may  promote 
the  gradual  diminution  in  size  and  even  the  disappearance  of  myomata, 
either  spontaneously  or  under  the  influence  of  rational  resolvent  treat- 
ment. West  draws  attention  to  the  analogies  which  may  be  estab- 
lished, from  this  point  of  view,  between  a  myoma  and  a  tuberculous 
bronchial  ganglion,  both  being  capable  of  undergoing  softening  as  well 
as  calcareous  induration.  West  also  thinks,  and  I  share  his  opinion, 
that  absorption  of  a  myoma  without  notable  alteration  of  the  tissue  is 
not  impossible,  but  might  take  place  by  regressive  evolution  as  opposed 
to  the  progressive  evolution  which  has  given  it  birth. 

Fibromata  may  be  attacked  by  softening,  liquefaction  and  suppura- 
tion. Sometimes  they  are  red,  the  whole  tumour  appearing  inflamed; 
they  become  oedematous,  fluctuating,  giving  rise  to  a  collection  of 
serosity,  blood  and  pus,  very  difiicult  to  diagnose  and  threatening  to 
terminate  by  dangerous  peritoneal  rupture,  or  they  may  become  sepa- 
rated towards  the  uterine  cavity  by  a  kind  of  maceration  in  the  san- 

'  Bourdillet  presented  a  specimen  to  the  Socicte  anatomique ;  the  patient 
had  been  in  M.  Mauriac's  wai'd  in  the  Hospice  cles  Menagcs. 

-  Michel  Morus  counted  thirty-two  calcareous  nuclei  in  a  fibrous  tumour. 
Louis,  R.  Lee  and  Velpeau  have  also  mentioned  remarkable  cases  of  the  same 
alteration  (Truraet,  These  sur  les  tumeurs  de  Vuterus,  p.  76.  Paris,  1851). 
Ashwell  mentions  four  cases  in  the  Gazette  hebdomad.,  1854,  p,  410. — Louis 
Mayer  and  Lehnerdt  each  describe  a  new  case  (Monatsclirift  fiir  Gehurtsh, 
18G9,  Bd.  xxxiii,  S.  241). — Also  Lumpe  [Gazette  hebdomad.,  18()(),  p.  71(5). — • 
And  Mordret  [Annales  de  f/ynecologie,  t.  xi,  p.  135). 

^  Medic. -Chirurg.  Tr(in.?actions,  xxiii,  1810. 

''   Concretiona  calcnleuses  de  la  viatrice. — Acad,  de  cliir.,  v,  1. 


654 


UTERINE    DISEASES   IN   DETAIL 


guineous  fluids  which  bathe  them. — Sometimes  they  are  only  partially 
attacked  by  inflammation,  softening,  suppuration  or  gangrene,  either 
on  the  surface  or  in  the  centre,  where  a  cavity  is  hollowed  out,  com- 
pared by  Cruveilhier^  to  an  eagle-stone. — When  clustered  together, 
cysts,  either  single  or  multiple,  may  be  developed  in  the  tissue  between 
the  fibromata,  which  may  acquire  a  great  size  and  become  the  seat  of 
hsemorrhage  or  suppuration  and  even  be  taken  for  ovarian  cysts. — 


Fig.  361. — Uterus,  containing  an  ovum  with  an  embryo  of  about  two  months, 
compressed  between  two  fibi'omata,  a  large  posterior  pelvic  one  and  a 
smaller  anterior  hypogastric  one.  The_  patient  was  operated  upon  :  she 
died  thirty  hours  afterwards  (Barnes,  Etudes  cliniques  sur  les  tumeurs 
retro-uterines,  in  Annales  de  gynecologie,  t.  ix,  p.  443.  Paris,  1878). 

Cancerous  degeneration  has  not  been  observed  in  fibroma.  It  may  be 
propagated  from  the  neighbourhood,  but  is  never  developed  there  in 
the  first  instance ;  and  fibroma  and  cancer  very  seldom  coincide. 

What  influence  do  fibromata  exercise  (ya.  fecundation,  pregyiancy  and 
delivery?"" — There  is  no  doubt  that  the  presence  of  myomata  diminishes 
the  number  of  conceptions  and  increases  that  of  abortions  and  miscar- 
riages. Out  of  605  patients  (of  whom  500  were  married  and  sterile 
or  had  become  sterile)  seen  by  Marion  Sims,  119  had  fibrous  tumours 
(not  including  cases  of  polypi). — Pregnancy  is  not  impossible,  but  it 
seldom  follows  its  normal  course :  whether  the  presence  of  the  fibrous 
tumour  prevents  the  free  development  of  the  uterus  or  whether  it  de- 
termines hsemorrhage  it  often  causes  abortion. — Delivery  may  be 
impossible;  it  is  always  difficult,  dangerous,  complicated,  and  it 
exposes  to  troublesome  consequences.     According  to  Tarnier,^  out  of 

'  Anai.  path.,  liv.  13,  pi.  6. 

2  Yoch,  Des  hysteromes  au  point  de  vue  de  la  generation.  These  de  Paris, 
1874. — Lefour,  Des  fibromes  uterins  au  point  de  vue  de  la  grossesse  et  de 
V accouchement.  These  de  concours  pour  I'agregation.  Paris,  1880. 

^  Societe  de  chirurgie,  Feb.  10,  1869. 


FIBROUS    TUMOTJES  65 

42  cases,  delivery  only  terminated  spontaneously  8  times ;  it  required 
the  use  of  forceps  6  times,  version  6  times,  induction  of  premature 
labour  once,  embryotomy  once,  enucleation  of  the  tumour  once, 
Csesarean  operation  14  times ;  the  malady  caused  death  5  times  before 
delivery  (of  these  42  patients  only  13  were  cured)  ;  sessile  fibromata  are 
displaced  with  the  uterus ;  their  ascension  at  the  time  of  delivery  is 
produced  by  the  contraction  or  shortening  of  the  longitudinal  fibres ; 
they  are  therefore  less  dangerous  at  this  time  than  pediculated  tumours ; 
but  they  expose  more  to  hsemorrhage  afterwards ;  patients  who  escape 
may  succumb  to  metro-peritonitis,  to  softening,  to  suppuration  de- 
veloped not  only  in  the  uterus  but  in  the  fibromata  themselves  (Bayle, 
Lisfranc,  Barnetche). 

What  influence  does  pregnancy  in  its  turn  exercise  on  the  development 
of  fibrous  tumours  ?^  In  spite  of  the  interest  which  Gueniot  imparted 
to  this  question  by  showing  that,  apart  from  the  influence  of  preg- 
nancy, a  fibroma  may  be  attacked  by  hypertrophy,  softening  and  sup- 
puration, we  must  admit  with  Ashwell,  West,  Yirchow  and  all 
pathologists,  that  pregnancy  is  one  of  the  conditions  which  most  pro- 
mote the  development  of  these  tumours.  My  experience  accords  with 
that  of  Guyon,  Bailly  and  others,  that  there  is  no  doubt  that  the 
increase  in  the  size  of  myomata  takes  place  at  the  menstrual  period 
and  during  pregnancy ;  it  is  the  same  with  their  softening  and  change 
of  position ;  but  it  is  more  doubtful  whether  they  resume  their  former 
size  and  still  more  whether  they  become  atrophied  in  following  the 
retrograde  evolution  of  the  organ  after  parturition.  In  speaking  of 
the  termination  of  these  tumours  I  shall,  however,  mention  cases  in 
which  they  have  disappeared  after  delivery,  and  even  during  pregnancy, 
according  to  some  writers. 

Diagnosis — signs  common  to  fibromata — subjective  signs. — The  first 
symptom  which  the  patient  notices  is  metrorrhagia,  sometimes  neither 
preceded  by  local  pains  nor  by  fatigue.  The  loss  of  blood  usually 
coincides  with  the  menstrual  period,  in  the  beginning  at  least,  and  is 
therefore  menorrhagic;  at  other  times,  or  at  a  later  period,  metror- 
rhagia occurs.  Excessive  menstruation  and  hsemorrhages  in  the  inter- 
calary period  are,  in  half  of  the  cases  at  least,  the  first  symptoms  which 
betray  the  presence  of  a  fibroma.^  In  women  who  have  ceased  to 
menstruate  haemorrhage  is  also  frequently  the  first  symptom.  It  some- 
times alleviates  the  acute  lumbar  pains  from  which  patients  suffered 
and  gives  a  false  confidence  by  misleading  them  as  to  the  real  cause  of 
this  loss  of  blood.     The  haemorrhage  depends  on  the  fluxion  which  the 

'  See  Forget,  BecJierches  sur  les  corps  fibreux  et  les  polypes  de  I'uterus  con. 
sideres  pendant  la  grossesse  et  apres  I' accouchement,  in  Bulletin  gen.  de 
therap.,  1846. — Forget,  Gueniot,  Tamier,  &c.,  Discussion  on  the  same  subject 
in  Bulletin  de  la  Societe  de  chirurg.,  1868,  1869. — Em.  J.  Lambert,  Essai 
sur  les  grossesses  compliquees  de  myomes  uterins.    Paris,  1870. 

"  In  88  women  suffering  from  myoma  before  the  menopause,  West  (op.  cit., 
p.  272)  observed  45  cases  of  disordered  menstniation,  either  as  to  frequency 
or  abundance,  or  both  simultaneously  ;  15  cases  of  dysmenorrha'a,  4  of  diminu- 
tion in  the  quantity  of  menstrual  blood,  and  44  cases  of  hajmorrhage  occurring 
in  the  intercalary  period. 


656  UTERINE    DISEASES    IN    DETAIL 

increase  of  the  fibroma  keeps  up  in  the  womb  and  on  the  alteration  of 
the  uterine  raucous  membrane  owing  to  the  presence  of  this  organic 
lesion.  It  increases  when  the  fibrous  body,  in  place  of  remaining 
interstitial,  has  become  pediculated,  being  a  still  more  prominent 
symptom  in  the  history  of  polypi  than  in  that  of  fibroids.  Expulsive 
hypogastric  pains  accompany  the  menses.  They  sometimes  extend  to 
the  hips  and  thighs,  and  especially  along  the  sciatic  nerve.  There  is 
also  dull  mechanical  pain,  pelvic  fulness,  weight,  painful  pressure  on 
the  sacrum,  dragging  in  the  groins  and  loins.  Earlier  or  later  leucor- 
rhoea  supervenes,  being  sometimes  a  mucous,  glairy,  transparent  or 
opaque  discharge,  sometimes  sanguinolent  or  purulent,  its  viscosity  in- 
dicating that  it  comes  from  the  uterine  cavity.  This  glairy  discharge 
is  very  abundant  in  some  patients. 

Dysuria,  vesical  tenesmus  or  complete  retention  of  urine,  produced 
by  the  pressure,  elevation  or  dragging  of  the  bladder  by  the  uterus, 
may  occur  in  the  beginning  or  when  the  fibroids  have  attained  a  certain 
size  or  are  situated  in  the  periphery.  These  symptoms  are  very 
common,  as  West  has  noticed  them  in  21  patients  out  of  40 ;  accord- 
ing to  Hervez  deChegoin,  they  may  even  be  the  first  that  are  observed. 
They  are  often  remarked  before  constipation.  The  difficulties  of  de- 
fecation, especially  when  marked,  may  be  said  to  be  less  common  than 
those  of  micturition.  Constipation  may  not  even  exist:  is  this  the 
result  of  the  normal  anteversion  of  the  uterus  or  is  it,  as  Clarke-^ 
thought,  because  the  tumour  does  not  correspond  in  its  form  to  the 
shape  of  the  pelvis,  and  being  prevented  by  its  size  from  entering  the 
cavity,  rests  on  the  pubis  and  on  the  promontory,  without  either  com- 
pressing the  rectum  or  the  sigmoid  flexure  which  is  to  the  left  ?  Con- 
stipation may,  however,  become  so  complete  as  entirely  to  prevent  the 
normal  passage  of  fecal  matter,  determining  symptoms  of  strangula- 
tion. This  occurs  especially  when  the  fibroid  has  become  stony. 
Nelaton,"  in  a  case  of  absolute  constipation  in  which  the  rectum  was 
so  flattened  that  no  sound  would  pass,  performed  the  operation  for 
artificial  anus  as  the  only  means  of  prolonging  the  life  of  the  patient, 
who  lived  for  eight  days.  I  have  seen  analogous  cases.  Alterations  of 
the  neighbouring  organs  may  extend  much  farther.  Strange  displace- 
ments have  been  described,  e.g.  the  rectum  pushed  to  the  right,  the 
bladder  on  one  side  or  the  other,  or  extending  upwards  as  far  as  the 
navel ;  gradual  wearing  away  and  perforation  of  the  bladder  and  rectum 
have  been  seen.  Soir^  has  seen  a  fibrous  tumour  the  size  of  the  fist 
perforate  the  uterus  and  linea  alba,  and  escape  through  the  gangre- 
nous skin  of  the  hypogastrium  in  the  form  of  a  black  and  fungous 
mass. 

Objective  signs. — The  speculum  is  of  no  use  in  the  diagnosis  of  a 
fibroma.  Palpation  permits  the  assumption  of  the  existence  of  these 
organic  alterations,  especially  when  much  developed,  multiple  or  pro- 
jecting towards  the  peritoneum,  when  they  give  a  nodulated  form  to 

'  Observ.  on  Diseases  of  Females,  i,  279.  London,  1821. 

^  Gnyon,  op.  cit.,  p.  49. 

^  Mem,,  de  hi  Sac.  de  cliirurcj.  de  Paris,  1851. 


FIBROUS    TUMOUES  657 

the  uterus  or  are  distinctly  perceived  round  this  organ.  Vaginal 
touchj  however,  is  infinitely  superior  to  the  two  preceding  means  of 
exploration ;  associated  with  palpation,  rectal  touch  and  the  use  of  the 
sound,  which  serve  as  complementary  or  auxiliary  means,  it  alone  can 
lead  to  a  certain  diagnosis. 

The  association  of  touch  and  palpation  with  the  use  of  the  sound 
not  only  allows  the  difference  in  thickness  of  the  two  uterine  walls  to 
be  appreciated  ;  the  mobility  of  the  catheter  and  the  direction  in  which 
it  is  carried,  the  reverse  of  the  natural  or  apparent  situation  of  the 
organ,  show  that  the  uterine  cavity  is  both  enlarged  and  deformed. 
Vaginal  touch  should  be  practised  in  different  attitudes  and  at  various 
times,  especially  during  menstruation  and  metrorrhagia,  when  the 
cervix  is  open ;  for  fibrous  bodies  and  polypi  present  themselves  at  the 
orifice  at  these  times,  returning  into  the  uterine  cavity  afterwards.  In 
order  to  facilitate  digital  touch  we  may,  like  Simpson,  dilate  the  cervix 
with  sponge  tents,  only  we  must  be  prepared  to  act  immediately  in 
case  of  haemorrhage,  either  injecting  iodine,  giving  ergot,  and  plugging 
if  we  have  to  do  with  an  interstitial  fibroma,  or  operating  if  the  fibroma 
is  pediculated. 

When  a  fibroma  by  its  size  and  weight  can  overcome  the  natural 
means  of  fixity  of  the  uterus,  it  forces  this  organ  to  incline  towards 
the  side  which  it  occupies,  more  frequently  in  lateroversion  than  in 
anteversion  and  especially  than  in  retroversion. 

When  of  considerable  size  the  influence  of  volume  is  greater  than 
that  of  weight :  instead  of  bending  the  uterus  to  its  own  side  it  pushes 
it  to  the  opposite  side,  taking  its  point  d'appiii  on  some  portion  of  the 
pelvic  cavity,  the  sacrum,  the  cotyloid  surface  or  the  margin  of  the 
coccyx.  If  it  becomes  so  large  as  no  longer  to  be  contained  in  the 
pelvis  it  is  forced  to  rise  into  the  abdominal  cavity,  dragging  the  uterus 
with  it,  thus  producing  the  opposite  condition  to  the  prolapsus  which 
the  presence  of  the  fibroma  had  produced  in  the  beginning. 

II.  Distinctive  signs  of  interstitial,  sub-mucous,  and  sub-peritoneal 
fibromata. — Interstitial  fibromata  present  different  symptoms,  accord- 
ing to  whether  they  are  situated  in  the  fundus  of  the  uterus,  enlarging 
its  dimensions  transversely,  or  occupying  the  walls  and  increasing  its 
cavity  longitudinally.  Those  of  the  fundus  may  completely  reverse 
the  position  of  the  uterus,  making  the  exact  limit  between  the  tumour 
and  the  uterus  very  difficult  to  define;  sometimes  the  fundus  of  the 
uterus  remains  thick,  whilst  the  layer  which  covers  the  fibroma  on  the 
side  of  the  uterine  cavity  is  so  attenuated  as  to  make  spontaneous 
enucleation  possible,  of  which  Barth,^  Bernutz,^  and  several  other 
writers  have  given  examples ;  at  other  times  the  fundus  of  the  organ 
is  so  equally  divided,  that  the  uterine  cavity  is  preserved  and  may 
become  the  seat  of  a  pregnancy,  as  in  the  cases  mentioned  by  Cruveil- 
hier,^  and  by  others.*     Those  of  the  walls  are  less  favorable  to  the 

'  Bulletin  de  la  Societe  anatomique,  1850,  p.  82. 
2  Gazette  hebdomad.,  1866,  p.  763. 
^  Anat.  pa,thol.,  ii"^  liv.,  p.  45. 

■♦  Ingleby,  Gaz.  mcd.,  1839,  p.  73— Pillore,  Gaz.  des  hnpit,  1854,  p.  547.— 

42 


658  UTERINE    DISEASES    IN    DETAIL 

accomplishment  of  the  uterine  functions ;  they  may  be  prolonged  into 
the  cervix  where  they  can  be  reached  by  operation_,  they  may  efface 
the  cavity  of  the  body  by  pressing  together  the  mucous  membranes  of 
the  two  uterine  walls  in  their  whole  extent,  or  these  membranes  may 
even  become  inflamed,  ulcerate  and  adhere  together  at  several  points.^ 
The  continuity  of  the  myoma  with  the  fibrous  bundles,  the  muscular 
trabeculse  and  the  vessels  persisting  longer  here  than  in  sub-mucous 
and  sub-serous  myomata,  it  is  not  surprising  that  these  interstitial 
tumours  attain  a  larger  size  than  the  others,  sometimes  simulating 
pregnancy.  The  entire  wall  of  the  uterus  is  in  a  condition  analogous 
to  that  of  pregnancy,  the  muscular  fibres  are  hypertrophied,  the 
vessels  dilated,  the  mucous  membrane  hypersemiated.^  Sometimes  on 
the  contrary,  the  uterus  is  atrophied ;  then  the  myomata  are  small, 
they  become  indurated  and  calcareous  ;  occasionally  they  become  very 
large;  in  these  cases  the  atrophy  of  the  uterus  seems  to  be  produced 
secondarily.^  Interstitial  fibromata  whether  simple  or  compound, 
most  frequently  occupy  the  posterior  wall  of  the  uterus  which  is 
normally  the  thickest.  They  produce  in  the  womb  changes  of  size, 
form,  situation  and  capacity  presenting  the  greatest  varieties. 

Sub-mucous  fibromata. — Though  seldom  multiple,  they  may  coincide 
with  intra-parietal  and  sub-serous  myomata ;  but  when  at  all  large, 
they  are  seldom  accompanied  by  important  intra-parietal  tumours. 
When  voluminous,  they  may  adhere  to  the  uterus  by  a  broad  base,  it 
being  impossible  for  them  to  become  pediculated  or  to  descend  into 
the  uterine  cavity  without  dragging  after  them  the  fundus  of  the 
uterus.  Usually,  however,  before  appearing  at  the  orifice,  they  are 
sufficiently  separated  from  the  uterine  wall  to  be  only  adherent  by  a 
pedicle  hke  a  cord  of  variable  resistancy,  very  distinct  from  the 
tumour  and  apparently  holding  it  suspended  from  the  womb  and 
liable  to  spontaneous  rupture.  One  of  the  most  important  points  to 
be  decided  with  regard  to  treatment  is  whether  there  is  a  broad  base 
or  a  pedicle.  Scanzoni  used  to  seize  the  portion  of  the  tumour  visible 
at  the  orifice  with  Museux's  forceps  and  try  to  impart  movements  of 
rotation  to  it,  which  could  only  be  possible  in  the  case  of  a  narrow 
pedicle.  The  migration  of  sub-mucous  fibroids  provokes  very  charac- 
teristic changes  in  the  uterus.  It  excites  in  the  mucous  membrane  an 
irritation  producing  softening,  injection,  haemorrhages,  cedema,  a  muco- 
sanguinolent  or  muco-purulent  secretion;  the  uterine  cavity  is  in- 
creased in  its  vertical  diameter,  whilst  the  two  opposite  surfaces  are 
placed  more  or  less  in  contact  with  each  other ;  in  the  end  the  cervix 

Leguerie,  Gaz.  rtied.,  1854,  p.  412. — "Weber,  Monatschrift  fur  Gehurtsk.,  1864, 
Bd.  XXV,  S.  157. — Ostertag,  id.,  id.,  Bd.  xxv,  S.  317. — Spiegelberg,  id.,  id.,  Bd. 
xxviii,  S.  426. — Lorimer,  id.,  id.,  Bd.  xxix,  S.  394. — Gueniot,  Des  tumeurs 
fibreuses  deV uterus  pendant  la  grossesse  et  I' accouchement.  Paris,  1868. 

1  Chassaignac,  Btdletin  de  la  Societe  anatomique,  t.  xviii,  p.  10. 

-  Carl  Venzel,  Die  KranJihciten  des  Uterus.  Mayence,  1816,  Taf.  xi,  a,  b. — • 
Hooper,  Morhid  Anatomy  of  the  Human  Uterus,  pi.  v,  a,  h. — Eobert  Lee, 
Medico. -Chirurg.  Transact.,  vol.  xix,  p.  122,  pi.  ii. — Lebert,  Traite  d'anat. 
paihol,  Atlas,  pi.  clvii,  fig.  2. 

3  Walther,  Ueber  fibrose  Korper,  S.  16. 


FIBROUS   TUMOURS  659 

becomes  softened,  shortened  and  reduced  to  a  simple  ring,  as  in  the 
last  months  of  pregnancy,  the  os  being  enlarged  to  allow  the  fibroid  to 
pass. 

Sub-peritoneal  fibromata. — In  place  of  presenting  the  characters  of 
uterine  tumours  like  the  two  preceding,  they  have  those  of  abdominal 
tumours  as  regards  situation  and  symptoms.  The  symptoms  vary 
according  to  the  part  of  the  uterus  from  which  they  have  originated,  the 
portion  of  the  abdomen  where  they  are  situated,  the  volume  wliich 
they  acquire,  the  transformations  which  they  undergo.  They  may 
cause  errors  of  diagnosis  and  real  danger  from  these  various  points  of 
view.  The  origin  of  subperitoneal  fibromata  is  near  the  peritoneum  or 
just  below  this  membrane.  These  tumours  remain  attached  to  the 
uterus,  and  if  largely  developed,  the  womb  appears  to  be  only  an 
appendage  to  them  {see  fig.  362) ;  they  project  more  or  less  consider- 


FiG.  362. — Uterus  siuTounded  and  suiToonnted  by  pediculated  sub-peritoneal 
fibroids  {ad.  nat.  Farre). 

ably  towards  the  pelvis  or  abdomen,  even  the  largest  being  seldom 
completely  freed  from  the  uterine  tissue.  Some,  however,  end  by 
being  only  connected  with  the  uterus  by  a  long  and  narrow  pedicle ; 
Martini  has  seen  one  weighing  6  lbs.  connected  with  the  uterus  by  a 
pedicle  two  inches  long  and  one  wide;  Gaubric^  found  in  the  right 
iliac  fossa  a  tumour  reaching  to  the  gall  bladder,  attached  by  a  thin 
pedicle  to  the  right  half  of  the  cervix ;  Cruveilhier^  saw  a  fibroid 
11  lbs.  in  weight  connected  by  a  long  pedicle  of  the  diameter  of  a  quill 
pen  with  the  right  superior  angle  of  the  uterus.  They  seldom  appear 
singly,  they  coexist  with  intra-parietal  or  with  internal  myomata. 
They  are  usually  hard,  having  a  tendency  to  become  calcareous,  proba- 
bly by  muscular  atrophy  and  arrested  nutrition.  These  fibroids  may 
even  be  detached  spontaneously  from  the  uterus  and  continue  to  live 
either  completely  free  in  the  abdomen,  or  fixed  by  accidental  adhe- 
sions; in  such  cases  there  was  necessarily  rupture  of  the  pedicle. 
They  often  give  rise  to  no  symptom,  and  do  not  even  affect  the  regu- 

'  Memoires  de  medecine  et  de  chirurgie  pratique,  p.  271.  Lyons,  1835. 
^  bulletin  de  la  Societe  anatoiniqiie,  1841,  p.  235. 
2  Anatomie  pathologique,  t.  iii,  p.  G67. 


660  UTERINE    DISEASES    IN    DETAIL 

larity  of  menstruatioTi.  Bayle^  has  mentioned  a  remarkable  case  of 
this  iniiocuity.  Like  interstitial  or  submucous  fibromata  they  are, 
however,  often  accompanied  by  considerable  hsemorrhage.  Some  by 
their  weight  and  displacement  have  been  seen  to  produce  torsion  of  the 
uterus  on  its  axis  (Kg.  363),  or  the  spontaneous  separation  of  the 
body  and  cervix,  others  have  caused  symptoms  of  intestinal  strangula- 
tion by  pressure  on  the  intestine,^  or  even  laceration  of  the  intestine 
owing  to  a  fall  on  the  belly  in  the  case  of  an  osseous  tumour;^  lastly, 
general  compression  and  difficulty  of  respiration  and  circulation, 
asphyxia  in  fact,  may  be  produced  owing  to  their  size.*  Subperitoneal 
fibromata  are  those  which  are  most  easily  recognised  by  })alpation  and 
touch  combined.  There  is  no  uncertainty  except  with  regard  to  those 
which  arise  from  the  upper  portion  of  the  posterior  wall,  which  must 
not  be  confounded  with  uterine  flexions  or  peri-uterine  tumours  (the 
sound  associated  with  vaginal  and  rectal  touch  enables  a  diagnosis  to 
be  made),  or  with  hard  pelvic  or  abdominal  tumours,  such  as  ovarian 
cysts  and  solid  tumours  (the  general  health  is  much  more  affected  in 
these  latter  cases  than  in  cases  of  subperitoneal  tumours). 

III.  Distinctive  signs  of  fibromata  and  other  uterine  and  peri- 
uterine maladies. — Pregnancy  is  distinguished  from  them  by  the 
menses  being  suspended ;  but  there  are  abnormal  pregnancies,  either 
in  aged  women,  or  with  continuation  of  the  catamenia  or  haemorrhage, 
hence  the  error  made  by  Bayle^  in  a  case  of  this  kind.  In  order  to 
avoid  such  a  mistake  the  patient  should  be  examined  frequently  at 
regular  intervals.  Balottement  should  be  tried  after  the  fourth  month, 
and  the  physician  should  endeavour  to  determine  the  absence  of 
nodulations,  and  observe  whether  there  is  the  wine-red  colour,  the 
softening  of  the  cervix  and  the  oedematous  sensation  which  the  poste- 
rior wall  of  the  gravid  uterus  sometimes  presents ;  he  must  remember 
also  that  voluntary  movements  and  fcetal  heart  sounds  observed  in  the 
fifth  month  are  certain  signs  of  pregnancy.  The  existence  of  a  fibrous 
tumour  may  not  prevent  conception  although  not  allowing  of  uterine 
pregnancy  :  there  may  then  be  a  tubal  pregnancy,  as  in  the  case  seen 
by  Stoltz.^  Extra-uterine  pregnancy  alone  may  also  be  taken  for  a 
fibrous  tumour.'''  Lastly,  as  a  distinctive  sign,  we  should  notice  in 
cases  of  fibroids  whether  expulsive  pains  are  developed;  they  are 
frequently  present,  and  would  produce  abortion  if  the  uterus  contained 

'  Op.  cit.,  p.  79. 

^  It  is  the  only  mode  of  strangulation  by  fibromata  that  is  known.  Three 
cases  are  recorded  :  one  by  jSTelaton,  one  by  Duchaussoy,  both  mentioned  by 
Guyon  (op.  cit.,  p.  77),  and  another  by  Holdouse  :  flattening  o£  the  rectum, 
lumbar  anus,  death  the  tenth  day  {Transact,  of  Path.  Soc.  of  London,  vol.  iii, 
p.  371). 

^  Arnott,  Med.-Chir.  Transact.,  vol.  xxiii,  1840. 

*  Cruveilhier :  two  tumoui-s  in  the  same  patient,  one  of  11  lbs.  with  a  long 
thin  pedicle,  situated  in  the  right  hypochondrium  ;  the  other  of  22  lbs.,  filling 
the  pelvis  and  abdomen.     Op.  cit.,  p.  668. 

'"  Op.  cit.,  p.  80. — Fredet,  Annales  de  la  Societe  de  medecine  de  St.-Etienne, 
1865,  p.  205. 

^  Mentioned  by  Aran,  op.  cit.,  p.  850. 

'  Jobei-t  (de  Lamballe),  Gaz.  des  hopit.,  July  5,  1845. 


FIBROUS    TUMOUES 


661 


a  product  of  conception  in  place  of  a  fibroid. — We   should  remember 
that  after  delivery  the  presence  of  a  fibroma  in  the  uterus  may  expose 


/^5P^»f»r-. 


Fig.  363. — a,  enormous  sub-peritoneal  pediculated  fibroid,  accompanied  by 
intra-muscular  myomata  and  complicated  with  pregnancy,  in  a  woman  of 
42,  who  had  a  miscarriage  sixteen  years  previously  ;  transverse  diameter, 
32  in.,  vertical  diameter  14  in.  B,  left  kidney ;  c,  Wolifiau  cyst  ; 
D,  interstitial  fibroid  contained  in  the  right  cornu  of  the  uterus ;  E,  inser- 
tion of  tlie  peduncle  of  the  large  tumour  on  a  level  with  the  left  cornu 
(the  uterus  is  twisted  on  .its  axis)  ;  F,  left  ovary  and  round  ligament ;  g, 
right  ovary  and  round  ligament ;  H,  cervix  (Leon  Labbe,  Legons  de 
clinique  chirurgicale,  pp.  447,  452.     Paris,  1876). 

us  to  an  error  in  diagnosis  leading  us  to  think  there  is  a  second  child. 
Abortion  is  distinguished  by  the  coincidence  of  pains  and  hneraor- 
rhage,  the  pains  ceasing  with  the  hajmorrhage.  Prolapsus  of  the 
uterus  inverts  the  vaginal  walls,  which  does  not  happen  when  a  pedi- 
culated fibroid  passes  through  the  cervix.  The  mistake  is  more  easily 
made  if  the  fibroid  has  a  cavity  and  a  transverse  fissure  imitating  the 
cervix  into  which  tlie  finger  can  penetrate.  In  such  cases  the  fibroid 
has  sometimes  been  removed  under  the  impression  that  it  was  the 
uterus.      Levret,  Richeraud^  Cloquet^  Bosredon,  Velpeau,  Maree  and 


662  UTERINE    DISEASES    IN    DETAIL 

Dolbeau^  have  mentioned  cases  of  the  kind.  The  key  to  the  problem 
is  in  the  diagnosis  of  the  uterus  by  determination  of  the  cervix^  vaginal 
cul-de-sac,  the  relations  of  the  fundus,  the  direction  of  the  ureter^,  the 
displacement  of  the  bladder.  Inversion  of  the  uterus  may  be  still 
more  easily  mistaken  for  a  fibroid.  The  error  has  been  committed  by 
W.  Hunter  and  Denman  and  followed  by  death  ;^  at  other  times 
patients  have  survived  the  mistake.^  In  these  cases,  which  are  rather 
numerous,  sometimes  simple  inversion  has  been  taken  for  a  fibroid,  at 
other  times  the  fibroid  has  been  rightly  diagnosed  but  not  the  inver- 
sion which  complicated  it.  In  order  to  distinguish  the  one  from  the 
other  two  facts  should  be  remembered  :  1,  in  inversion,  above  the  ring 
which  encircles  the  tumour,  a  furrow  or  closed  sinus  exists  all  round,  a 
cul-de-sac  of  moderate  depth  which  cannot  be  prolonged  into  a  uterine 
cavity  which  no  longer  exists ;  2,  the  fundus  no  longer  occupies  its 
usual  place  in  the  pelvis ;  by  means  of  vesical  catheterism  and  rectal 
touch,  or  by  means  of  a  male  catheter  introduced  into  the  bladder,  the 
point  of  which  is  directed  towards  the  uterine  infundibulum  (Mal- 
gaigne),  this  characteristic  displacement  of  inversion  can  easily  be 
ascertained^  at  least  in  most  cases ;  3,  acupuncture  may  be  utilised,  as 
I  have  already  said  apropos  of  inversion. 

Cancer  may  be  taken  for  a  fibroma  and  vice  versa,  especially  when, 
owing  to  the  gangrene  of  several  fibrous  tumours,  an  abundant  fcetid 
discharge  escapes  from  the  uterus ;  but  the  odour  of  the  discharge 
accompanying  the  presence  and  even  the  softening  of  the  fibroid  in  the 
uterine  •  cavity  differs  from  that  which  characterises  cancer :  the 
former  is  acid,  being  the  result  of  fermentation  and  heat ;  that  of 
cancer  is  not  only  fcetid  but  nauseous  and  putrid,  having  the  smell  of 
decomposition.  The  general  symptoms  differ  also ;  in  cancer  they 
are  very  serious,  characterised  by  cachexia  and  hectic  fever,  the  course 
of  the  disease  also  is  relatively  rapid ;  while  in  the  case  of  fibroid  they 
are  almost  limited  to  impoverishment  of  blood  and  to  ansemia.  The 
other  uterine  diseases  are  more  easily  distinguished  from  fibromata 
than  the  preceding.  Hypertrophic  elongation  differs  from  it  by  its 
regularity  of  form  and  the  cervical  elongation ;  uterine  cysts  by  fluc- 
tuation, softening,  or  the  cavities  which  they  contain  ;*  anteflexion  and 
retroflexion  (Fig.  364)  by  the  curve  which  has  to  be  described  by  the 
catheter  in  penetrating  the  uterine  cavity ;  engorgement  by  an  in- 
feriority of  size  and  weight,  a  less  considerable  displacement,  a  less 
irregular  tumefaction,  a  previous  delivery  or  abortion  ;  metritis,  by  the 
equal  tumefaction  of  the  two  walls,  the  ease  with  which  the  sound 
passes,  the  elevation  of  temperature,  the  acuteness  of  the  pains  caused 
by  pressure,  redness,  muco-purulent  or  purulent  leucorrhoea,  ulcera- 
tion, granulations,  &c.,  as  well  as  by  the  relative  rarity  of  hsemor- 

^  Guyon,  op.  cit.,  p.  80. 

-  Robert  Lee,  Med.-Chirurg.  Trans.,  xx,  144. 

^  American  Journal  of  Med.  Sciences,  April,  1849. — Bloxam,  Gaz.  med.  de 
Paris,  1837,  p.  122. 

''  We  may,  like  Huguier,  complete  the  difFerential  diagnosis  between  a  hard 
fibroma  and  a  iitero-follicular  polypiis,  with  its  cavity  distended  by  a  fluid,  by 
making  an  exploratory  puncture. 


FIBROUS    TUMOURS 


663 


rhage.  Some  tumours  situated  outside  the  uterus  may  easily  be 
confounded  with  fibromata,  especially  with  pediculated  subperitoneal 
fibromata,  if  in  diagnosing  them  we  have  not  recourse  to  the  most 
exact  means  of  investigation, — The  first  of  these  in  frequency  is  retro- 
uterine hematocele  :  the  error  has  been  made.^  However,  the  history, 
the  frequent  suddenness  in  the  formation  of  the  tumour,  the  acuteness 
of  the  first  symptoms,  the  persistence  of  peri-uterine  adhesions,  the 
absence  of  a  pedicle,  the  site  in  the  retro-uterine  cul-de-sac  of  the  san- 
guineous effusion  which  is  at  last  absorbed,  the  absence  of  hsemor- 
rhage  and  of  complication  of  the  uterine  cavity,  the  almost  invariable 


Fig.  364. — Fibroma  projecting  trom  the  posterior  wall  of  the  uterus,  com- 
pressing the  rectum  and  simulating  uterine  retroflexion  (Barnes,  Annales 
de  Gynecologie,  t.  ix,  p.  441). 

position  of  the  uterus  immediately  behind  the  pubic  symphyses  and 
almost  on  the  median  line,  are  sufiiciently  distinctive  signs.  Eecta- 
vaginal  and  vesico-vaginal  ^  fibrous  tumours  are  more  easily  distin- 
guished. They  do  not  deform  the  cervix,  but  they  displace  it,  raising 
the  vaginal  cul-de-sac,  becoming  enveloped  in  it  in  place  of  depressing 
it,  always  having  between  their  convexity  and  the  corresponding  por- 
tion of  the  uterus  a  cul-de-sac  the  presence  or  absence  of  which  decides 
the  question.  It  is  less  easy  to  distinguish  hard,  osseous  or  osteo- 
cartilaginous tumours,^  especially  those  of  the  anterior  wall  of  the 
pelvis. 

Ovarian  tumours,  provided  they  are  not  too  voluminous,  pre- 
serve an  evident  mobility,  the  existence  of  which  is  undoubted 
when  the  patient  is  made  to  change  her  position  or  when  movements 

*  Voisin,  De  V hematocele  retro-uterine,  p.  193.  Paris,  I860. 
^  Dupuytren,  Cliniqtie,  iii,  326. 

^  Dolbeau,  Mem.  sur  l' enchonclrome  du  hassin  (Journ.  du  Progres),  1860. — 
Nekton,  Clinique,  par  W.  Atlee,  p,  707,  quoted  by  Guyon,  Tum.fihr.,  p.  49. 


664  UTERINE    DISEASES   IN    DETAIL 

are  communicated  to  the  tumour.  If,  however,  it  is  difficult  to  con- 
found them  with  interstitial  or  submucous  fibroids,  it  is  not  less  so  to 
distinguish  them  from  subperitoneal  fibrous  tumours  (especially  when 
the  latter  have  become  free  or  abdominal). 

It  is  well  to  remark,  with  regard  to  all  extra-uterine  tumours,  that 
they  push  the  womb  up  or  down,  according  to  whether  they  arise  from 
the  abdomen  or  the  pelvis,  in  place  of  dragging  it  directly  with  them 
as  uterine  fibromata  do.  We  may  also  remark  that  difficulties  of 
differential  diagnosis  increase  when  fibromata  become  inflamed,  sup- 
purate or  perforate  the  uterine  wall. 

Treatment. — The  frequency  of  fibromata  ought  to  call  attention  to 
the  treatment  which  these  tumours  require.  Loir,  in  examining  the 
uterus  in  40  old  women  met  with  fibrous  bodies  15  times. — Statistics 
prove  that  they  are  most  frequent  during  the  period  of  uterine  activity. 
Dupuytren,  out  of  57  patients  affected  with  fibroma,  met  with  52  in  those 
from  20  to  50  years  of  age;  Malgaigne,  out  of  51  patients,  found  40 
from  30  to  50  years  old;  VVest,  out  of  76,  mentions  67  between  20 
and  50  years;  Braun  and  Chiari  have  made  analogous  observations. 
We  may,  however,  find  them  in  young  girls  and  in  old  women.  Hardy^ 
operated  on  a  girl  of  17.  One  was  observed  in  a  child  of  9.  Trsezl^ 
saw  a  vaginal  polypus  in  a  child  of  16  months. — They  are  not  only 
developed  in  the  uterus,  but  also  in  the  appendages,  in  consequence 
of  the  identity  of  nature  of  the  muscular  envelope  common  to  these 
organs  :  this  frequency  is  proved  as  regards  the  ovaries,  Tallopian 
tubes,  broad  ligaments,  utero- rectal  ligaments  and  the  vagina;  I  have 
seen  them  in  these  various  organs,  with  their  characteristic  aspect, 
rounded,  firm,  hard,  elastic,  white  and  fibrous,  with  fibres  encircling 
several  centres.^ 

The  prognosis  from  the  reproductive  point  of  view  is  unfavorable : 
the  presence  of  myomata  in  the  uterus  diminishes  the  chances  of  con- 
ception, increases  those  of  abortion  and  leads  to  great  dangers  at  de- 
livery ;  it  mechanically  opposes  the  passage  of  the  child,  it  prevents 
the  uterus  from  contracting  after  the  expulsion  of  the  placenta  and 
exposes  to  hsemorrhages,  it  prevents  retrograde  evolution  of  the  organ 
and  becomes  the  source  of  inflammation,  softening,  peritonitis  and 
septiceemia.  From  the  point  of  view  of  danger  to  life  in  a  non-pregnant 
woman  it  is  much  less  serious  :  undoubtedly  the  presence  of  myomata 
affects  the  general  health  seriously  and  permanently,  owing  to  haemor- 
rhage and  to  the  development  of  the  parasitic  tumour  at  the  expense 
of  nutrition :  but  though  the  malady  is  often  incurable  it  is  seldom 
fatal. 

The  termination  of  the  malady  may  be  unfavorable  or  favorable. 
In  the  former  case,  it  may  threaten  life  in  several  ways  :  by  haemor- 
rhage, by  its  rapid  development  which  is  sometimes  arrested  by  the 

^  Monatschr .  filr  Gehurtsk.,  Bd.  xxv,  S.  358. 

8  Ibid.,  Bd.  xxii,  S.  227. 

3  According  to  Virchow,  if  tlie  usual  seat  of  myoma  is  the  body,  i.e.  the 
art  of  the  uterus  which  is  richest  in  muscular  tissue,  it  is  also  frequently 
ound  in  the  ovary,  rather  less  often  in  tlie  uterine  ligaments,  less  frequently 
still  in  the  cervix,  and  most  seldom  of  all  in  the  vagina. 


I 


FIBROUS    TUMOUES  665 

menopause,  by  compression  of  the  rectum,  by  suppuration,  by  gan- 
grene (a  termination  in  which  cure  may  be  bought  too  dearly),  lastly, 
by  perforation  of  the  uterus  and  organs  covering  it,  the  vesico- vaginal 
or  vagino-rectal  mucous  membrane,  the  abdominal  wall  and  the  peri- 
toneum in  various  directions. 

In  the  latter  case,  there  is  spontaneous  retrocession,  diminution,  or 
expulsion.  There  may  be  simple  tolerance  of  even  large  tumours 
sometimes  covered  with  calcareous  incrustations  :  this  is  what  happens 
in  old  women,  for  in  them  fibrous  bodies  seem  to  become  pediculated 
less  frequently  than  in  the  young.  Retrocession  may  take  place  spon- 
taneously either  under  the  influence  of  iodine  or  after  pregaancy  and 
parturition.  Theoretically  pregnancy  seems  to  promote  the  develop- 
ment as  well  as  the  absorption  of  fibromata ;  but  the  physician  ought 
to  take  advantage  of  the  period  following  delivery  to  prescribe  resol- 
vent treatment,  as  at  that  time  there  is  a  very  energetic  regressive 
tendency.  Spontaneous  expulsion  is  very  rare;  it  is  probable  that  the 
expulsion  of  polypi  has  often  been  confounded  with  that  of  true  inter- 
stitial tumours ;  it  coincides  with  the  expulsion  of  the  foetus  or  follows 
it  closely,  or  it  may  take  place  independently  of  gestation  and  delivery, 
by  enucleation  and  with  laceration  of  the  uterine  tissue,  usually  with 
colics  as  acute  as  those  of  labour  ;  it  may  require  surgical  assistance, 
and  is  sometimes  followed  by  profuse  haemorrhage.  Therefore  though 
fibroids  are  not  malignant,  they  become  serious  owing  to  the  hsemor- 
rhage  which  they  provoke,  to  their  becoming  jammed  into  the  pelvic 
cavity  and  to  the  enormous  size  which  they  may  attain.  Haemorrhage, 
however,  may  diminish  under  suitable  treatment  which  brings  into 
play  the  curative  processes  of  nature  (the  tendency  to  enucleation  and 
to  the  expulsion  of  the  fibroma).  It  is  the  same  with  other  sym- 
ptoms :  the  tumour  may  soften,  decrease,  shrivel,  become  encrusted, 
and  even  disappear  at  the  menopause.  It  is  therefore  important  to 
treat  the  symptoms,  moderate  the  development  of  the  tumour  and 
keep  up  the  general  health  of  the  patient  till  the  climacteric  age  is 
reached;  the  danger  is  much  less  afterwards.  West  thinks  that 
patients  should  be  reassured,  as  out  of  96  cases  he  has  only  had  one 
death  from  haemorrhage  and  two  from  utero- peritoneal  inflammation 
after  delivery.  However,  that  is  no  reason  for  neglecting  to  promote 
atrophy  of  the  myoma,  to  assist  the  uterus  to  expel  the  tumour  or  to 
interfere  directly  when  advisable. 

Medical  treatment  is  more  efficacious  than  might  be  supposed :  no 
other  should  be  used  at  first  in  cases  of  sub-peritoneal  tumours ;  as  to 
other  fibroids,  it  may  at  least  be  palliative  and  preparatory  to  surgical 
treatment.  It  includes  many  means  rightly  designated  by  Cruveilhier 
as  atrophic  treatment,  the  action  of  which  may  have  a  favorable  result, 
especially  when  patients  are  near  the  menopause.  It  consists  in  sub- 
duing pain  sometimes,  haemorrhages  frequently,  in  promoting  the 
spontaneous  enucleation  of  the  fibroid,  avoiding  all  causes  which 
stimulate  uterine  circulation,  in  bracing  the  constitution  and  promot- 
ing the  natural  resolution  of  the  tumour. 

Pain  seldom  requires  treatment  by  opium  or  belladonna.     Some- 


666  UTEEINE    DISEASES    IN   DETAIL 

times  we  may  follow  Clarke's  advice  to  push  the  uterus  and  the 
fibroid  it  contains  above  the  brim,  so  that  it  can  be  developed  without 
hindering  the  functions  of  the  pelvic  organs  by  painful  pressure. 
At  other  times  the  patient  may  be  eased  by  the  use  of  Bourjeaurd's 
abdominal  belt,  which  prevents  the  concussion  of  sub-peritoneal 
or  abdominal  tumours,  at  the  same  time  that  it  promotes  their 
resolution. 

Heemostasis  is  obtained  by  abdominal  applications,  cold  irriga- 
tions, long  continued  applications  of  ice,  or  better  still  very  hot  injec- 
tions morning  and  evening  for  ten  minutes  at  a  time,  the  general  and 
local  use  of  perchloride  of  iron,  alum,  acids,  tincture  of  cinnamon, 
tannin,  rhatany,  and  vaginal  plugging.  Savage,  of  the  Samaritan  Hos- 
pital in  London,  dilates  the  cervix  with  a  sponge  tent  and  then  injects 
tincture  of  iodine  (iodine  thirty  grains,  iodide  of  potassium  one 
drachm,  rectified  spirit  two  drachms,  water  three  ounces),  or  pure  ofii- 
cinal  tincture  of  iodine  into  the  uterus ;  the  injection  not  only  arrests 
the  hsemorrhage  but  diminishes  the  size  of  the  tumour,  according  to 
this  surgeon,  when  repeated  on  each  recurrence  of  the  hsemorrhage  for 
five  or  SIX  months.-^ 

In  order  to  remove  all  causes  of  disordered  uterine  circulation,  the 
patient  should  be  told  to  keep  her  bowels  regular  by  enemata  or  mild 
laxatives;  to  lie  on  her  back  with  the  knees  drawn  up,  especially 
during  menstruation  and  metrorrhagia ;  lastly,  complete  rest  should  be 
prescribed  for  the  diseased  organ,  i.e.  patients  should  be  dissuaded 
from  marriage,  while  those  who  are  married  should  be  advised  to  dis- 
continue intercourse,  with  the  double  object  of  saving  the  uterus  from 
excitement  tending  to  produce  hsemorrhage  and  the  hypernutrition  of 
the  fibroids,  and  of  preventing  the  possibility  of  pregnancy.  Ergot  is 
the  hemostatic  which  I  prescribe  most  frequently  with  the  double 
object  of  arresting  hsemorrhage  and  of  producing  the  spontaneous 
enucleation  of  the  tumour.  I  usually  prescribe  four  grains  of  freshly 
powdered  ergot  to  be  taken  from  one  to  six  times  a  day ;  I  sometimes 
substitute  pills  of  ergotine  and  continue  the  use  of  it  for  five  or  six 
days  after  every  monthly  period  for  some  time."  I  know  of  few  cases 
of  fibroids  which  have  not  been  improved  if  not  cured  by  the  use  of 
this  drug  associated  with  other  means  of  treatment  which  I  shall 
describe. 

In  cases  of  formidable  hsemorrhage  (where  an  operation  is  contra- 
indicated),  McClintock  and  West  assert  that  free  incisions  of  the 
cervix  almost  always  diminish  the  flow  of  blood.  Does  this 
act  by  depleting  the  uterus,  facilitating  the  escape  of  blood  and 
thereby  preventing  the  distension  of  the  organ,  or  by  producing  a 

^  Sims,  op.  cit.,  p.  121. 

-  Hildebrand  of  Kajnigsterg  has  tried  subcutaneous  injections  of  a  solution 
of  extract  of  ergot  (15  gr.)  in  water  and  glycerine  (aa  105  gi'.).  Inject 
from  15  to  30  drops.  Berlin  Klin.  Wochensch.,  June  17,  1872.— Baker 
Brown  {American  Journal  of  Obstetrics,  1877,  p.  38)  has  seen  eclampsia  occur 
after  injections  of  ergotine  for  a  large  fibroma,  but  this  is  the  only  case  re- 
corded.    They  are  now  largely  used. 


FIBROUS  TUMOURS  667 

certain  amount  of  indurating  and  cicatrising  metritis  ?  ^  It  is  not 
enough  to  subdue  the  hsemorrhage  without  dissipating  its  bad  effects 
by  tonics. 

As  for  the  spontaneous  absorption  of  the  tumour,  although  this 
result  cannot  be  counted  on,  remarkable  cases  of  it  have  been  known 
(I  have  myself  seen  such);  therefore  we  must  not  hesitate  to  prescribe 
resolvents.  Amongst  other  means  we  may  try  pills  of  hemlock,  mer- 
cury, preparations  of  gold,  bromine,  iodine,  the  alkalis  and  the  cura 
/amis.  I  prefer  the  following  :  the  long-continued  use  of  bromide  or 
iodide  of  potassium,  which  may  be  increased  from  15  gr.  to  45  gr. 
a  day,  diuretics,  milk,  nitre,  squills,  daily  friction  of  the  abdomen  and 
upper  and  inner  parts  of  the  thighs  with  mercurial  and  belladonna 
ointment ;  pessaries  and  suppositories,  or  rather  enemata,  of  this  oint- 
ment ;  a  large  abdominal  compress,  or  painting  the  hypogastrium  with 
iodine,  Yichy  water  or  an  alkaline  solution  taken  before  or  during 
meals,  alkaline  baths  and  mineral  waters  (Vichy,  Andabre,  Yals, 
Boulou,  Plombieres),  associated  with  hydropathy.  The  medical  treat- 
ment which  I  prescribe  for  fibro-myomata  is  the  following  :  a  diet  of 
meat  and  fish,  fresh  vegetables,  ripe  fruit,  stale  bread,  wine  diluted 
with  Bussacg  or  Orezza  water ;  alteratives  in  the  various  forms  just 
mentioned) ;  I  also  specially  recommend  my  patients :  1,  to  make 
vaginal  injections  on  the  bidet  for  ten  minutes  with  water  as  hot  as 
can  be  borne,  and  to  which  has  been  added  one  or  two  dessert-spoon- 
fuls of  a  solution  of  carbolic  acid  (from  ^  to  1  oz.  of  crystallised  car- 
bolic acid  to  a  quart  of  water) ;  2,  three  times  a  week  a  subcutaneous 
injection  of  15  drops  of  a  solution  of  ergotine  (15  gr.  of  ergotine 
dissolved  in  105  minims  of  water  and  105  minims  of  glycerine) ;  3,  three 
times  a  week  the  application  for  ten  minutes  of  a  rather  strong  con- 
tinuous current,  rendered  intermittent  by  means  of  a  metronome,  the 
positive  pole  being  applied  to  the  cervix  and  the  negative  pole  to  the 
abdomen.  Although  we  cannot  hope  to  cure  all  fibromata  we  may  by 
these  means  keep  them  in  check. 

Surgical  treatment  is  very  effectual.  In  the  numerous  cases  in  which 
it  can  be  applied  it  is  curative.  It  varies  according  to  whether  the 
fibrous  body  is  interstitial  or  detached  from  the  uterine  wall  and  only 
connected  with  the  peritoneum  or  mucous  membrane  by  a  more  or 
less  broad  pedicle.  In  this  latter  case  if  the  fibroma  is  subperitoneal 
or  abdominal,  and  if  operation  is  not  contra-indicated,  it  may  be 
removed  by  abdominal  section  performed  in  the  same  manner  as  for  ex- 
tirpation of  an  ovarian  cyst,"  an  operation  which  will  be  described  when 
we  come  to  ovariotomy.  If  the  jjediciilated fibroma  is  submucous,  and 
especially  if  it  has  escaped  from  the  cervix,  surgical  intervention  is 
indispensable :  it  consists  in  the  extirpation  or  destruction  of  the 
tumour  by  one  of  the  numerous  methods  apjjhcable  to  the  treatment 
of  polypi. 

^  Amilcar  Riconli,  Traitement  des  fihrumes  par  la  methode  des  incisions 
multiples  (Comment,  di.  medic,  et  chirurg.  Milan,  1st  year,  No.  1). 

2  W.  Atlee,  two  cases :  American  Journ.  of  Med.  Science,  Aj)i'il,  1845, 
April,  1855. 


668  UTERINE    DISEASES    IN    DETAIL 

In  the  former  case,  i.  e.  of  interstitial  fibroma,  surgical  intervention 
is  debateable;  it  is  surrounded  with  difficulties  and  often  with  danger. 
Its  aim  is  to  extirpate  the  tumour,  but  this  can  only  be  effected  by 
enucleation. 

The  methods  differ  as  does  the  facility  of  operation  according  to 
the  depth  at  which  the  fibroid  is  seated  (in  the  cervix  or  in  the  body), 
the  projection  which  it  makes  under  the  mucous  membrane,  the  thick- 
ness of  the  layer  of  uterine  tissue  covering  it,  tlie  adhesions  which  it 
has  contracted  in  the  kind  of  cyst  in  which  it  is  contained,  and  lastly, 
the  size  it  has  attained.  With  regard  to  depth,  if  the  fibroma  is  con- 
tained in  the  thichiess  of  one  of  the  two  cervical  lips  it  is  easy,  after 
having  slightly  drawn  down  this  organ,  or  having  separated  the 
vaginal  walls  by  means  of  dilators,  to  incise  the  mucous  membrane 
and  uterine  tissue  in  the  median  line,  to  reach  the  tumour,  to  rupture 
with  the  finger  or  handle  of  the  scalpel  the  connections  which  loosely 
unite  it  to  the  neighbouring  parts,  to  seize  it  when  necessary  at  the 
sides  with  tenaculum  hook  forceps  or  in  the  centre  with  a  corkscrew 
driven  into  the  tissue  itself,  and  to  enucleate  it  completely.  In  such 
cases,  unless  the  tumour  has  acquired  an  enormous  size,  there  is  no 
contra-indication  to  operation.  If  the  fibroma  is  contained  in  the 
cavity  of  the  body  the  orifice  must  be  previously  dilated.  Ergot  often 
produces  the  double  effect  of  pediculating  the  tumour  and  forcing  it 
powerfully  and  continuously  towards  the  orifice,  by  the  contractions 
which  it  excites  in  the  uterine  tissue ;  gradual  dilatation  of  the  cervix 
is  produced  by  pressure  of  the  tumour,  a  dilatation  similar  to  that 
determined  by  pressure  of  the  bag  of  waters  during  labour. 

When  the  dilatation  of  the  cervix  produced  by  the  expulsive  efforts 
is  insufficient,  it  should  be  facilitated  by  the  introduction  of  instru- 
ments into  the  uterine  cavity  to  dilate  or  divide  it.  I  prefer  prepared 
sponge  to  more  violent  means  because  its  slow  but  continuous  action 
produces  in  the  end  complete  dilatation  almost  without  causing  any 
pain.  Dilatation  is  facilitated  and  the  pain  of  it  diminished  by  cover- 
ing the  dilator  with  a  little  extract  of  belladonna.  In  1 814  Bonnie,i 
having  diagnosed  a  polypus  in  a  woman  subject  to  repeated  haemor- 
rhages, by  forcing  his  finger  into  the  os,  dilated  this  orifice  with 
sponge  tents  till  he  was  able  to  introduce  several  fingers  into  the 
uterus,  and  having  discovered  the  insertion  of  the  pedicle  applied  a 
ligature.  Dupuytren^  considers  simple  or  multiple  division  of  the 
cervix  better  than  dilatation.  This  eminent  surgeon  divided  it  in  one 
stroke  from  without  inwards,  whereby  he  avoided  injuring  everything 
except  the  tumour,  whilst  Velpeau  performed  the  same  operation  iu 
several  little  incisions  from  within  outwards.  The  incisions  should  be 
made  obliquely  when  possible,  and  should  be  multiple  rather  than 
single.  Whilst  recognising  the  utility  of  this  method  when  there  is 
danger  of  fatal  haemorrhage  and  urgent  necessity  for  the  removal  of 
the  fibrous  body,  I  think  it  is  usually  unnecessary,  and  that  gentle 
mechanical  dilatation  associated  with  the  use  of  ergot  is  sufficient  in 

'  Bulletin  de  la  FacuUe,  t  iv. 
^  Clinique  chir.,  in,  360. 


FIBROUS    TUMOUKS  669 

submucous  fibroids,  as  in  polypi,  to  allow  of  the  introduction  of  the 
fingers  and  instruments  into  the  uterus.  When  the  cervix  is  suffi- 
ciently dilated  to  admit  of  operation  the  uterus  is  drawn  down  if  neces- 
sary, the  index  finger  of  the  left  hand  is  then  introduced  into  the 
uterine  cavity,  the  form  of  the  tumour  diagnosed,  and  the  uterine 
tissue  covering  the  central  and  most  prominent  portion  incised  from 
above  downwards  with  a  probe-pointed  bistoury  ;  then  with  the  fingers 
or  the  handle  of  the  scalpel  the  fibroid  is  separated  from  its  envelope 
and  extracted.  Amussat  used  to  detach  the  tumour  by  beginning  at 
the  upper  part  and  working  downwards.  The  remaining  fragments  of 
mucous  membrane  or  uterine  tissue  contract,  cicatrise,  or  are  partially 
destroyed  by  suppuration. 

This  operation  is  not  very  difficult,  and  I  think  unattended  with 
much  danger  when  the  tumour  is  not  very  large,  when  it  is  free  from 
adhesions,  when  it  projects  towards  the  uterine  cavity  and  when  from 
the  long-continued  use  of  ergot  it  has  a  tendency  to  become  pedicu- 
lated.  I  have  performed  it  several  times  successfully.  Hsemorrhage 
resulting  from  division  of  the  vessels  of  the  uterine  wall  need  not  be 
feared  any  more  than  spontaneous  hsemorrhage.  It  is  true  that  the 
uterine  wall  has  been  dragged  away,  that  it  has  been  divided  and  the 
peritoneal  cavity  penetrated  ^  in  this  operation,  but  if  under  the  influ- 
ence of  the  long-continued  use  of  ergot  the  tumour  has  become  suffi- 
ciently prominent  to  authorise  the  surgeon  to  decide  on  extraction,  it 
is  to  be  presumed  that  the  subperitoneal  portion  of  the  uterine  wall  in 
the  interstices  of  which  the  fibroma  is  contained,  is  thicker  than  the 
submucous  portion,  and  consequently  protected  from  the  danger  of 
these  accidents.  The  important  point  is  not  to  operate  in  a  hurry  or 
before  enucleation  has  been  facilitated.  The  adhesions  which  Berard " 
found  between  the  fibroma  and  the  cavity  containing  it  are  almost  the 
only  obstacles  that  cannot  be  foreseen,  and  which  it  is  difficult  to  remove. 

But  the  chief  difficulty  is  the  size  of  the  tumour.  To  this  cause 
must  be  attributed  the  great  mortality  attending  such  operations.^ 
Amussat^  first  performed  ablation  of  these  large  fibroids ;  since  then 
different  methods  have  been  adopted,  varying  with  the  site  of  the 
fibroids  according  as  they  are  seated  in  the  walls  or  fundus. — In  cases 
of  Jibroids  of  the  walls  the  tumour  may  be  divided  by  two  incisions, 
separated  below  but  touching  above,  and  enclosing  a  triangular  seg- 
ment or  the  third  of  the  fibroma,  the  ablation  of  which  will  greatly 
facilitate  the  extraction  of  the  two  remaining  thirds.  Or,  like  Maisson- 
neuve,'^  after  dividing  the  tumour  longitudinally  into  halves  and 
enucleating  all  the  lower  portion  of  one  of  these  halves  we  may  divide 
the  latter  from  below  upwards  in  a  direction  parallel  to  its  surface  and 

'  Le  Piez,  Journal  de  chir.  de  Malgaigne,  1845,  p.  90. 

*  Bulletin  de  la  Societe  anatomique,  1849,  p.  82. 

^  Hutcliinson  {Med.  Times  and  Gazette,  August,  1857)  has  collected  .39 
cases  of  similar  operations ;  out  of  18  enucleations  with  the  hot  iron  there 
were  12  cures,  6  deaths  ;  out  of  15  enucleations  with  caustics  9  cures,  6 
deaths  ;  out  of  6  unfinished  operations  4  cures,  2  deaths. — Guyon  (op.  cit.,  p. 
114)  counts  not  less  than  lU  deaths  out  of  17  operations. 

■•  Bulletin  de  la  Societe  de  chir.,  1849. 


670 


UTEEINE    DISEASES    IN    DETAIL 


thus,  by  the  extraction  of  a  superficial  slice,  facilitate  the  enucleation 
of  the  deep  portion;  the  other  half  is  easily  extracted  afterwards. — 


Fig.  365. — Sub-mucous  fibroma,  pi'ojecting  into  the  vagina  through  the  dilated 
cervix.  Attempted  extraction  by  the  vagina  lasting  two  and  a  half  hours. 
Death  from  haemorrhage  and  exhaustion  nine  and  a  half  hours  afterwards. 
(Emmet,  op.  cit.,  p.  582,  fig.  100).  I  have  seen  a  similar  case,  except  that 
the  patient  died  of  septicaemia. 

With  regard  to  interstitial  fibromata  of  the  fundus,  it  is  difficult  to  reach 
them  if  they  cannot  be  drawn  through  the  cervix ;  but  even  when  this 
is  the  case  two  difficulties  present  themselves ;  the  thinness  of  the 
uterine  wall  which  separates  them  from  the  peritoneum,  and  the 
difficulty  of  distinguishing  the  exact  limit  of  the  fibroid  on  the  fundus 
of  the  womb,  which  is  necessarily  inverted  by  the  descent  of  the 
tumour. 

When  obliged  to  perform  such  operations  we  should  adopt  Jarja- 
vay's  method.  Instead  of  cutting  the  tumour  transversely  it  should 
be  divided  longitudinally  by  a  vertical  section  with  great  care,  so  that 
each  hemisphere  may  be  separated  right  and  left  and  the  upper  boun- 
dary between  the  tumour  and  the  uterine  tissue  easily  defined.  After 
operation  the  inversion  is  reduced. 

Whatever  method  be  adopted  we  must  endeavour  to  effect  extraction. 
Such  an  operation  is  fatal  if  left  unfinished.  The  denuded  or  divided 
fibrous  body  becomes  softened  and  tumefied,  causing  ineffectual  ex- 
pulsive efforts  and  infectious   suppuration  which   always  terminates 

fatally. 

To  sum  up,  it  is  very  difficult  to  estimate  the  dangers  of  the  operation 
beforehand.  Apart  from  haemorrhage,  death  is  too  often  caused  by 
peritonitis,  phlebitis,  pyaemia,  resulting  from  traumatism  of  the  uterus  in 


FIBROUS    TUMOURS  671 

women  exhausted  by  loss  of  blood.  Therefore  we  should  not  under- 
take the  extirpation  of  fibromata  of  any  considerable  size  unless  it  is 
decidedly  indicated,  the  life  of  the  patient  being  in  continual  danger 
from  haemorrhage.^  It  should  never  be  undertaken,  moreover,  until 
resolvent  treatment  has  first  been  tried ;  the  continuous  current,  sub- 
cutaneous injections  of  ergotine,  very  hot  vaginal  injections,  perchloride 
of  iron  and  bromide  or  iodide  of  potassium  being  the  means  most 
likely  to  succeed.  When,  however,  operation  is  successful  it  may  efi'ect 
a  radical  cure  and  be  followed  by  conception,  normal  pregnancy  and 
delivery.^  When  the  fibromata  are  voluminous,  multiple  and  do  not 
project  towards  the  uterine  cavity,  extirpation  of  the  whole  uterus  with 
its  appendages  has  been  attempted  by  abdominal  section,  as  in  ova- 
riotomy. Clay^  ties  the  vessels  of  the  broad  ligaments  and  then 
secures  the  cervix  by  a  ligature  of  circular  thread.  Kceberle,*  by  a 
single  puncture  from  before  backwards,  passes  two  metallic  ligatures 
through  the  uterine  mass,  and  tying  one  on  each  side  removes  each 
half  of  the  organ  with  the  corresponding  broad  ligament  successively 
by  constriction.  This  method  has  been  adopted  by  the  majority  of 
surgeons.  I  shall  revert  to  this  operation  when  describing  that  of 
ovariotomy,  merely  mentioning  now  in  passing  that  this  daring  sur- 
gical operation  has  been  successfully  performed;  as,  however,  the 
mortality  has  hitherto  been  considerable,^  it  is  best  to  reserve  our 
opinion  upon  the  future  of  an  undertaking  which  but  a  short  time  ago 
would  have  been  condemned  as  unwarrantably  rash. 

During  pregnancy  the  indications  presented  by  fibromata  vary 
according  to  the  symptoms  produced ;  it  may  be  necessary  to  subdue 
uterine  contractions,  to  induce  abortion  or  to  remove  a  tumour  of  the 
cervix  when  it  causes  serious  hsemorrhage.^  During  labour'^  an  inter- 
stitial fibrous  tumour  may  force  the  surgeon  to  have  recourse  to 
forceps,  version,  embryotomy,  Csesarean  section,  puncture^  or  ablation^ 

^  Jarjavay,  Des  operations  applicables  aux  corps  fibreux  de  V uterus. 
These  de  concours.  Paris,  1852. 

^  Grimsdale,  A  Case  of  Artificial  Enucleation  of  a  Large  Fibroid  Tumour 
of  the  Uterus,  ivith  some  Remarks  on  the  Surgical  Treatment  of  these 
Tumours;  in  Liverpool  Medico-Chirurg .  Journal,  Jan.,  1857. 

2  Observations  on  Ovariotomy,  Statistical  and  Practical.  Also  a  Successful 
Case  of  Entire  Removal  of  the  Uterus  {Transact,  of  the  Obstet.  Soc.  of 
London,  vol.  v,  1864). 

■•  Documents  pour  servir  a  I'histoire  de  I'extirpation  des  tumeurs  fibreuses 
de  la  matrice,  pur  la  methode  sus-pubienne  [Qaz.  med.  de  Strasbourg,  1864). — 
Operations  d'ovariotomie,  pp.  79,  98,  105.  Paris,  1865. 

^  Routh,  On  some  Points  connected  with  the  Pathology,  Differential  Diag- 
nosis  and  Treatment  of  Fibrous  Tumours  of  the  Uterus  (The  Lancet,  1863, 
1864). — Kceberlc,  Operations  d'ovariotomie,  p.  98.  Paris,  1865.  He  lost  three 
patients  out  of  six. — Caternault,  Essai  sur  la  gastrotomie  dans  les  cas  de 
tumeurs  fibreuses  peri-uterines.  Paris,  1866.  List  of  76  cases.  Nearly  two- 
thirds  of  the  patients  died  from  lucmorrhage. 

•^  Merrimann,  polyjius  ligatured  during  pregnancy.  Cure.  Delivery  one 
month  afterwards.  See  also  the  remarkable  work  already  mentioned  of  R. 
Lefour. 

7  Puchelt,  De  tumoribus  in  pelvid.  partum  impedientibus.  Heidelbero-,  1840. 

^  Cazeaux,  Bulletin  de  la  Soc.  de  chir.,  94. 

^  Danyau,  Bulletin  de  I'Acad.  de  med.,  1851. — Bevv£  medico.-chirurg.,  1861. 


672  UTEEINE    DISEASES    IN    DETAIL 

of  the  tumour  itself.  We  should,  however,  know  when  to  wait ;  for 
we  know  by  experience  that  delivery  may  exceptionally  take  place 
spontaneously  and  almost  without  accidents.  To  sum  up  the  indica- 
tions to  be  followed  in  such  cases  they  may  be  arranged  in  the  following 
order  :  1,  expectation ;  2,  attempted  reduction  or  retropulsion  of  the 
tumour  above  the  brim  (Stoltz  places  this  foremost) ;  3,  ordinary  forceps 
with  or  without  continuous  traction  (preferred  by  Depaul  and  Gueniot 
to  version)  ;  4>,  version  (preferred  by  West  and  Tarnier  to  forceps), 
it  may  help  in  the  reduction  of  the  tumour;^  5,  embryotomy;  6,  enu- 
cleation of  the  tumour  (unfortunately  the  boundaries  and  connections 
of  it  are  very  uncertain  and  hsemorrhage  is  to  be  feared)  ;  7,  Csesarean 
section  ;^  8,  induction  of  premature  labour  (a  doubtful  point,  for  the 
tumour  may  rise,  even  in  the  third  month,  as  Blot's  case  shows)  ;  9, 
induced  abortion  (to  be  reserved  for  cases  in  which  the  life  of  the 
mother  is  in  serious  danger).  After  delivery,  if  accidents  occur  which 
do  not  allow  of  our  waiting  till  the  fibroid,  which  hypertrophied  during 
gestation,  resumes  its  original  size  or  atrophies,  examples  of  which 
have  been  given  by  Chaill}/^  and  Cazeaux,'''  the  tumour  may  be 
extracted  immediately,  as  in  the  cases  recorded  by  Guyot,^  Danyau,^ 
Langenbeck'^  and  Keating,^  or  only  after  the  uterus  had  resumed  its 
usual  size,  as  Ramsbotham^  advised,  in  order  to  take  advantage  of  the 
regressive  tendency  which  the  uterine  tissue  possesses  at  that  time  to 
institute  energetic  resolvent  treatment,  which,  while  it  might  cause  the 
disappearance  of  the  tumour,  would  at  the  same  time  exercise  a  favor- 
able action  on  the  involution  of  the  uterus. 


Polypi  and  Moles 

Polt/pi  and  moles  are  excrescences  of  various  kinds  having  their 
origin  in  one  or  other  of  the  uterine  tissues  or  in  certain  elements  of  a 
fertilised  ovum.  The  hypertrophy  of  these  tissues,  or  rather  the  pro- 
perty which  the  uterine  tissues  and  the  embryonic  envelopes  possess  of 
becoming  hypertrophied,  is  the  immediate  cause  of  the  development  of 
both  structures.  Folypi  are  kinds  of  hypertrophic  vegetations  of  a 
portion  or  of  one  of  the  elements  of  the  uterine  tissue  proper,  of  its 
mucous  membrane  or  of  its  vascular  system.  Moles  are  organised 
bodies  arising  from  the  envelopes  of  aproductof  conception,  implanted 

'  Too  few  cases  have  been  recorded  to  allow  o£  our  deciding  between  these 
two  methods  (forceps  or  version). 

2  Etlinger,  Obseroationes  obstetricice.  Bonnse,  1854. 

^  Traits  de  I'art  des  accouchements,  p.  572.  Paris,  1861. 

4  Ibid.,  p.  620.  Paris,  1862. 

*  Levret,  op.  cit.,  p.  220. 

^  Beclierches  sur  les  polypes  fibreux  de  I'uterus  {Journ.  de  cJiir.  de  Mal- 
gaigne,  1846). 

'   Schinidt's  Jahrbuch,  August,  1851.     Operation  followed  by  death. 

^  American  Journal  of  Med.  Sciences,  May,  1858.  Operation  followed  by 
death. 

^  Obstetric.  Med.  and  Surg.,  p.  224.  London,  1856.  A  woman  of  30  years, 
delivered  three  weeks  previously.     Cure. 


POLYPI    AND    MOLES  673 

in  the  uterine  tissue^  deriving  from  it  a  morbid  hypertrophic  growth 
and  presenting  themselves  under  the  two  very  different  forms  of  grape- 
like clusters  and  fleshy  bodies. 

1.   Uterine  Poli/pi 

Polypi  1  are  tumours  which  differ  from  all  others  by  the  existence, 
if  not  of  several  feet  as  the  etymology  seems  to  indicate,  at  least  of  one 
foot  or  pedicle  or  contracted  portion,  by  which  they  are  attached  to 
the  uterus.  Whether  this  pedicle  is  broad  or  narrow,  short  or  long, 
whether  the  tumour  is  contained  in  the  womb  or  expelled  by  muscular 
contractions,  the  polypus  is  always  characterised  by  the  existence  of  a 
pedicle.  These  tumours  are  classed  together  because  the  presence  of 
a  pedicle  suffices  to  produce  a  group  of  special  symptoms  and  special 
indications  common  to  ail  tumours  of  this  kind.  They  are  all  due  to 
the  hypergenesis  and  hypertrophy  of  one  or  more  of  the  elements 
which  enter  into  the  composition  of  the  uterine  substance.  There  are 
therefore  only  three  principal  kinds  of  uterine  polypi :  the  fibrous  or 
muscular,  much  the  most  common  ;  the  mucous  less  common ;  the 
vascular  the  rarest  of  all.  Hypergenesis  may  affect  several  of  the 
uterine  elements  simultaneously  so  as  to  produce  composite  polypi,  m 
which  these  various  elements  enter  in  various  proportions ;  lastly,  the 
polypi  themselves  are  subject  to  various  alterations  which  more  or  less 
modify  their  structure. 

1.  Fibrous  polypi  are  nothing  but  interstitial  fibromata  or  myomata 
which  have  become  submucous  and  pediculated.  They  are  sometimes 
enormous,  sometimes  multiple,  at  other  times  degenerated,  fibro- 
cystic, softened  in  their  centre,  or,  on  the  contrary,  indurated,  cartila- 
ginous, encrusted  on  their  surface  and  stony  throughout. 

2.  Mucous  polypi  are  formed  by  the  hypergenesis  of  the  elements  of 
the  mucous  membrane  and  especially  of  the  follicles  of  this  membrane. 
Sometimes  they  are  very  small,  very  transparent,  more  sub-epidermic 
than  mucous,  meriting  the  name  of  vesicular  or  epithelial."  At  other 
times  they  are  produced  by  the  accumulation  of  mucus  in  a  cervical 
gland  the  orifice  of  which  is  obliterated,  in  one  of  Naboth's  eggs 
which  acquires  a  size  varying  from  that  of  a  pea  to  that  of  a  large 
nut,  and  which,  instead  of  remaining  sessile  or  buried  in  the  uterine 
tissue,  is  gradually  detached  from  it,  becoming  pediculated  ;  at  other 
times  they  are  formed  by  the  development  of  analogous  phenomena  in 
several  follicles  of  the  body  or  cervix  in  such  proportions  that  they 
may  form  considerable  tumours,  cysts,  cystic  or  hollow  polypi,  to 
which  the  name  of  follicular  or  utero-follicular  ^  has  rightly  been 
given,  producing  sometimes  simultaneously  the    hypertrophy   of  the 

^  The  name  polypus,  applied  to  certain  tumours  of  the  uterus,  seems  to  date 
as  far  back  as  Moschion  ;  but  it  is  only  since  the  time  o£  Ruysch  {Obsero. 
Anat.,  6)  that  this  word,  which  till  then  was  confined  to  polypi  oE  the  nose,  has 
been  generally  employed  to  designate  the  analogous  excrescences  of  the  uterus. 

^  Montfumat,  Etudes  sur  les  polypes  de  VuUrus,  1867. 

^  Huguier,  Des  kystes  de  la  matrice  et  du  vagin.  Mem.  de  la  Soc.  de 
chirurg.,  t.  i. — Luna,  Des  kystes  folliculaires  de  la  matrice  et  des  polypes 
utero-folliculaires.  Theses  de  Paris,  1852. 

43 


674  UTEEINE    DISEASES  IN    DETAIL 

fibro-plastic^  fibrous   and  vascular   elements  of  the  uterine  mucous 
membrane.     These  utero- follicular  polypi  may  be  vascular  containing 

cavities  in  which  sanguineous  effusions  are 
produced,  and  occasionally  becoming  in 
themselves  the  source  of  haemorrhages,  un- 
like the  majority  of  fibrous  polypi  which 
excite  uterine  hsemorrhage  without  them- 
selves being  the  source  of  it. 

3.  Vascular  polypi  are  rare,  their  ex- 
istence being  denied  by  some  writers,  whilst 
by  others  they  have  been  confounded  with 
sanguineous  or  fibrinous  polypi  (hsemato- 
mata  of  Yirchow),  which  are  only  fleshy 
Fig.  366. — Vesicular  poly-  moles  or  uterine  clots  ;  by  Levret  they  were 
pus  of  the  cervix  pro-  recognised  under  the  name  of  fungous 
SS^L'Tentilgh  polypi-  They  are  usually  small,  harder 
the  speculum  (from  a  ^^d  smaller  when  developed  in  the  cervix, 
drawing  by  Meyer).  softer,  more  spongy,  more  bleeding  when 

developed  in  the  uterine  cavity.  On  section 
more  blood  is  discharged  than  one  would  suppose.  I  have  seen 
seven  of  the  size  of  a  cherry  on  the  cervix;  two  of  them,  of 
a  dark  red  colour,  seemed  to  be  painfully  swollen  at  certain  periods, 
especially  during  menstruation,  like  hsemorrhoidal  tumours.  Perhaps 
they  should  be  included  in  the  class  of  mucous  polypi  rather  than  in 
that  of  fibrous  polypi,  the  vascular  hypertrophy  which  causes  them 
only  being  produced  at  the  expense  of  the  vessels  of  the  mucous  mem- 
brane and  not  of  the  tissue  proper  of  the  uterus. 

Diagnosis — subjective  signs. — Usually  at  the  commencement  of  the 
malady  the  general  and  local  symptoms  are  very  vague ;  the  polypus 
causes  expulsive  pains,  to  which  later  on  are  added  radiating  pains, 
dull  achings  and  neighbouring  disorders. — These  are  accompanied  by 
menstrual  disorders,  at  first  by  menorrhagia,  afterwards  by  metror- 
rhagia, due  in  the  majority  of  cases  to  thefluxionary  movements  which 
the  presence  of  the  polypus  excites  in  the  womb.  Hsemorrhage  is  the 
greatest  danger,  caused  by  the  presence  of  polypi  in  the  uterus ;  it 
may  carry  the  patient  off  without  medical  intervention.^  I  give  the 
woodcut  of  a  fibro-mucous  polypus,  which,  notwithstanding  its  small 
size,  caused  such  serious  hsemorrhage  that  if  the  patient  had  not  suc- 
cumbed to  an  intercurrent  malady  ablation  would  have  been  required 
to  save  her  life. — Mucous,  purulent  or  sanguinolent  leucorrhoeais  pro- 
duced in  the  interval  between  the  haemorrhages  or  simultaneously  with 
them,  owing  to  the  irritation  just  described  in  the  internal  membrane 
of  the  uterus.  Yomiting,  dyspepsia,  impoverishment  of  blood,  are 
the  usual  consequences  of  the  reaction  produced  upon  the  uterus  and 
nervous  system  by  the  presence  of  a  polypus.  Conception  is  not 
impossible  but  abortion  is  very  common. 

1  Saxinger  {Monatschr.  filr  GebiirtsTc.,  1868,  Bd.  xxxii,  S.  329)  relates  a  case 
in  which  death  was  caused  by  spontaneous  and  repeated  hsemorrhage  from  a 
mucous  polypus,  the  removal  of  which  was  not  attempted. 


POLYPI    AND   MOLES 


675 


Objective  signs. — Direct  examination  is  more  or  less  easy  and  the 
results   more  or  less  satisfactory  according  to  whether  the  polypus  is 


Fig.  367. — Fibrinous  uterine  polypus  of  Velpeau  and  Kiwisch,  or  free  polypous 
hematoma  of  Vircliow.  A  large  portion  of  the  fcetal  placenta  is  still 
adherent  to  the  projecting  placental  insertion  {Die  KranTchaft.  Geschwulste). 

still  hidden  in  the  uterine  cavity,  plugging  the  orifice,  floating  in  the 


Fig.  368. — Fibro-mucous  polypus,  re- 
markable for  the  abundance  of  the 
meti'orrhagia  produced  in  spite  of 
its  small  size.  \,  tumour  in  situ  ;  b, 
tumour  raised  so  as  to  show  its  pos- 
terior surface. 

vagina  or  invading  the  pelvic  cavity.     The  tumour  does  not  become 


676 


UTERINE    DISEASES    IN    DETAIL 


pediculated  in  passing  through  the  cervix :  the  pedicle  is  acquired 
whilst  the  tumour  is  still  within  the  uterine  cavity.  When  the  tumour 
is  still  retained  in  the  uterine  cavity  the  cervix  must  be  dilated  ;  the 
finger  is  then  introduced  into  the  uterus^  and  with  the  help  of  the 

sound  we  try  to  reach  the  highest  part 
of  the  tumour  in  order  to  discover  the 
pedicle.  The  tumour  may  even  be  seized 
with  the  forceps,  when  by  a  movement 
of  rotation  or  torsion  we  find  out 
whether  it  is  sessile  or  pediculated.  Fre- 
quently we  can  discover  nothing  unless 
the  investigation  is  made  during  men- 
struation. The  polypus  often  re-enters 
the  uterine  cavity  after  having  been  seen 
at  the  orifice.  This  alternate  appearance 
and  disappearance  may  occur  several 
times.^  When  the  tumours  have  de- 
scended into  the  cervix  or  into  the 
vagina  it  is  of  capital  importance  to 
discover  the  cervix  or  os.  After  having 
ascertained  the  size  and  consistency  of 
the  intra-vaginal  tumour  the  examining 
finger  should  discover  the  state  of  the 
cervix  externally  and  internally,  ex- 
ploring the  external  surface,  the  utero- 
vaginal culs-de-sac,  the  circumference  of 
the  orifice  and  the  cervical  cavity,  and 
endeavouring  to  penetrate  into  the  cavity 
of  the  body  to  discover  the  insertion  of 
the  pedicle. 

Differential  diagnosis. — It  is  much 
easier  to  distinguish  polypi  than  fibro- 
mata from  other  tumours  producing  deformity  of  the  uterus.  Preg- 
nancy, cystocele,  vaginal  hernia,  prolapsus,  cervical  hypertrophy, 
cannot  be  confounded  with  them. 

There  are  only  two  diseases  the  differential  diagnosis  of  which  is 
somewhat  difficult :  inversion  and  cancerous  cauliflower  excrescences. — 
With  regard  to  inversion  we  must  remember  that  the  body  of  the 
uterus  is  no  longer  found  in  its  normal  position  in  the  pelvic  cavity, 
nor  can  the  uterine  cavity  be  traced  beyond  the  circular  cul-de-sac 
which  forms  the  limit  between  the  neck  and  the  body  of  the  womb. — 
As  to  cancer,  even  the  cauliflower  variety  differs  so  greatly  from  polypus 
in  the  aspect  and  consistency  of  its  tissue,  the  breadth  of  its  insertion 
over  the  whole  surface  of  the  cervix  or  of  one  of  its  lips,  the  inequality 
of  its  surface,  &c ,  that  it  is  difficult  to  make  a  mistake  as  to  its 
nature. 

*  Larchev,  Contributions  a  I'histoire  des  polypes  fibreux  intra-uterins  a 
apparitions  intermittentes  {Archiv.  gener.  de  nied.  Paris,  1867). — Robert 
Johns  {Gaz.  med.,  1858,  p.  128). 


Fig.  369. — Pediculated  cervical 
polypus  (frora  Boivin  and 
Duges). 


POLYPI    AND    jUOLES  677 

Treatment. — There  are  two  principal  indications  ;  1,  to  provoke  the 
expulsion  of  the  polypus  or,  by  dilatation  of  the  os,  to  facilitate  the 
introduction  of  instruments  for  ablation ;  2^  to  remove  the  polypus 
by  operation. 

I.  The  first  indication  is  fulfilled  by  all  the  medical  and  surgical 
means  which  I  have  described  as  employed  in  the  treatment  of  inter- 
stitial fibromata  and  submucous  fibroids.  The  rules  of  their  applica- 
tion are  the  same  as  in  cases  of  submucous  fibromata^  induced  abortion 
and  extraction  of  any  foreign  body  from  the  uterine  cavity.  Some- 
times expulsion  and  even  complete  detachment  is  effected  spontaneously 
(out  of  13  cases  of  spontaneous  cure  it  has  been  observed  10  times^  in 
the  3  other  cases  the  polypus  was  destroyed  by  suppuration),  but  the 
uterine  contractions  are  sometimes  so  violent  and  continuous  that  they 
may  produce  attenuation^  mortification,  and  perforation  or  rupture  of 
the  uterus.i 

II.  The  second  indication  is  fulfilled  by  direct  surgical  intervention 
which,  to  the  honour  of  the  art  be  it  said,  is  usually  successful.  The 
treatment  of  polypi  constitutes,  as  Velpeau  has  justly  remarked,  one 
of  the  triumphs  of  surgery.  The  methods  used  for  the  destruction  of 
polypi  of  the  other  organs  have  been  successfully  applied  to  the  abla- 
tion of  uterine  polypi.  They  are  :  cauterisation,  crushing,  torsion, 
ulcerative  ligature,  extemporaneous  ligature  or  ecrasement  and  exci- 
sion. These  methods  should  neither  be  adopted  nor  rejected  without 
consideration.  There  are  some  which  are  preferable  to  others,  and 
applicable  to  the  majority  of  cases,  such  as  ligature,  ecrasement  and 
excision;  these  may  be  regarded  as  the  best  methods.  Cauterisation 
and  crushing  are  extreme  measures  applicable  to  the  body  and  not  to 
the  pedicle  of  the  polypus;  torsion  is  not  without  danger,  but  this 
exceptional  method  has  its  indication  and  ought  to  be  adopted  in 
cases  of  polypi  of  a  special  nature  or  in  certain  conditions.  The 
general  methods  themselves  ought  not  to  be  applied  indifi'erently  to  all 
polypi ;  one  or  other  is  preferable  according  to  the  point  of  insertion 
of  the  polypus,  the  size,  consistency,  structure  and  vascularity  of  the 
tumour.  Before  describing  these  various  methods  and  their  indica- 
tions or  contra-indications  I  may  remark  that  cauterisation  is  only 
applicable  to  vascular  or  fungous  tumours,  or  to  those  contained  in  the 
uterine  cavity  and  which  cannot  be  seized  by  any  instrument ;  crushing 
is  applicable  in  similar  cases,  especially  to  intra-uterine  or  very  hard 
tumours,  the  pedicle  of  which  can  neither  be  reached  nor  divided  nor 
yet  ligatured,  and  upon  which  caustics  would  have  but  little  eff'ect. 
Torsion  is  applicable  to  the  ablation  of  small  mucous  follicular  or  very 
vascular  polypi,  the  pedicle  of  which  may  be  ligatured  beyond  the 
point  on  which  torsion  is  brought  to  bear,  but  is  dangerous  in  cases 
of  large  and  hard  pediculated  fibromata,  the  tissue  of  which  is  con- 
tinuous with  the  uterine  fibres,  for  laceration  may  occur  beyond  the 
pedicle,  affecting  the  uterine  wall  itself;  ligature  is  preferable  in  cases 

^  Larclier,  De  la  rupture  spontanea  de  I'uterus  et  de  qiielques  autres  particu- 
larites  dans  leurs  rapports  avec  les  polypes  fibreux  intra-uterins  {Archiv.  gen. 
de  med.,  1869). 


678  UTEEINE  DISEASES    IN    DETAIL 

of  large,  very  vascular,  utero-follicular,  cystic,  or  even  fibrous  polypi 
when  there  is  a  probability  of  the  existence  of  large  vessels  in  the 
pedicle,  or  when  it  is  applicable  as  a  precautionary  measure  to  be 
followed  immediately  by  excision;  extemporaneous  ligature  and 
ecrasement  are  applicable  under  the  same  circumstances  when  the 
absence  of  hsemorrhage  and  tolerance  on  the  part  of  the  patient  allow 
of  constriction  of  the  pedicle  being  carried  to  the  point  of  section  or 
laceration  in  place  of  waiting  for  ulceration,  thus  sparing  the  patient 
and  surgeon  the  drawbacks  of  sloughing  of  the  tumour;  lastly,  exci- 
sion is  preferable  in  all  cases  of  pediculated  fibromata,  for  experience 
proves  that  there  are  no  large  vessels  in  the  pedicle,  and  that  it  is  even 
applicable  to  other  polypi  provided  hemorrhage  can  be  arrested  by  ice, 
very  hot  injections,  cauterisation,  perchloride  of  iron  and  plugging, 

1.  Cauterisation. — This  is  only  employed  for  very  small  tumours  of 
the  cervix,  or  for  larger  polypi  coDtained  in  the  body,  and  which 
cannot  be  reached  by  instruments.  It  may  be  applied  in  the  form  of 
nitrate  of  silver,  acids,  caustic  potash,  the  actual  cautery  for  cervical 
polypi  and  even  for  a  polypus  of  the  body ;  but  it  is  dangerous  in  the 
latter  case,  and  should  only  be  applied  very  exceptionally.  The  gal- 
vano-cautery  may  also  be  used  after  Middeldorpf^s^  method  or  Paque- 
lin's  thermo-cautery. 

2.  Orushiiig. — This  may  be  performed  with  my  uterine  forceps, 
either  straight  or  curved.  Simpson  used  very  powerful  small  forceps ; 
Thierry  a  pair  of  very  strong  curved  toothed  forceps;  Nelaton  a 
punch-forceps ;  Eichet  crushing  forceps.  It  is,  however,  to  be  feared 
that  the  tissue  of  the  polypus,  being  only  partially  crushed  and  not 
immediately  extracted,  may  become  tumefied,  may  mortify  at  some 
points  and  give  rise  to  strangulation  and  putrefaction. 

3.  Evulsion  is  performed  with  polypus  forceps  with  concave  blades 
which  are  rough,  perforated  or  grooved,  so  as  to  fit  tightly  together. 
It  is  applicable  to  the  ablation  of  mucous  polypi,  small  cystic,  follicu- 
lar polypi  and  small  vascular  polypi  of  the  cervix.  The  pedicle  should 
always  be  compressed  with  elbow  forceps  above  the  point  at  which 
traction  is  made. 

4.  Torsion,  though  dangerous  for  fibrous  polypi  with  a  broad 
pedicle  merging  into  the  uterine  tissue,  is  useful  in  the  ablation  of 
small  mucous  and  vascular  polypi  on  account  of  its  rapidity  and  com- 
pleteness. I  have  frequently  removed  such  tumours  in  a  few  seconds ; 
and  for  this  purpose  have  had  forceps  made  with  elbowed  blades 
deeply  grooved  fitting  perfectly  into  each  other,  by  means  of  which 
the  pedicle  of  the  fungous  or  varicose  tumour  is  easily  seized,  whilst 
torsion  is  performed  lower  down  with  other  forceps,  till  the  tumour  is 
detached  from  the  uterus.^  My  uterine  forceps  are  usually  sufficient 
for  this  operation.  The  actual  cautery  should  be  applied  to  the  point 
of  insertion  in  order  to  prevent  reproduction  of  the  polypus. 

'  Ressel,  De  polyporum  iiteri  extirpatione  viethodo  galvano-caustica  in- 
stituta.  Diss,  inaug.  Vratisl.,  1857,  with  plates. 

^  Puech  mentions  two  cases,  proving  that  torsion  is  applicable  even  to  large 
polypi  when  applied  with  proper  precautious  {Annates  Cliniques  de  Montpellier, 
1857,  p.  218). 


POLYPI  AND    MOLES 


679 


5.  Ligature. — This  was  recommended  by  Pare  and  Guillemeau, 
adopted  by  Levret  ^  and  Desault,^  and  further  improved  by  Niessen/ 
Mayor/  and  others.  The  nature  of  the  ligature,  the  manner  of  apply- 
ing it  round  the  pedicle  and  the  method  of  constriction  are  variable, 


Fig.    370. — Ordinary   polypus 
forceps  with  crossed  blades. 


Ei(J.  371. — Polypus  forceps 
with  sliding  fastener. 


having  been  improved  and  modified  so  as  to  be  applicable  to  all  cases, 
and  to  allow  of  the  ligature  being  introduced  into  the  interior  of  the 
uterus  provided  the  cervix  is  sufficiently  dilated.  Levret's  ligature 
was  silver  wire,  a  means  of  constriction  at  once  flexible  and  resistant, 

'  Memoire  sur  les  polypes  de  la  matrice  et  du  vagin.  Acad,  de  chirurg., 
1749. — Observations  sur  la  cure  radicale  des  polypes  de  la  matrice.  Paris, 
1759. 

2  Journal  de  cliirurgie,  t.  iv. — CEuvres  cliirurg. 

3  Dissertatio  de  p)olypis  uteri  et  vagina,  novoque  ad  eorum  ligatiiram  in- 
strumento.  Goottingen,  1785. 

''  Nouveau  systeme  de  dcligation  chirurgicale.  Lausanne,  1837. 


680  UTERINE   DISEASES   IX   DETAIL 

and  whicli  can  be  managed  by  the  fingers  alone.  Iron  wire  may  be 
substituted,  but  it  has  the  drawback  of  oxidising,  and  of  breaking 
before  the  tumour  falls ;  ordinary  strong  waxed  thread  or  whipcord  is 
better;  silk  may  also  be  used  and  when  well  waxed  is  the  most  flexible 
and  resistant  of  all.  I  prefer  an  elastic  ligature^  however,  to  all  of 
these.  Instead  of  the  ligature  we  may  employ  the  method  adopted 
by  Gensouli  of  seizing  the  pedicle  with  polypus  forceps  furnished 
with  curved  blades  for  continuous  constriction.  Aveling  invented  his 
polyptrite  to  serve  instead  of  forceps. 

The  mode  of  applying  the  ligature  round  the  pedicle  is  equally 
variable.  —  Levret  used  two  cannulse  soldered  together  laterally, 
through  which  the  silver  thread  was  passed  so  as  to  form  a  loop 
between  the  two  extremities  at  one  end  ;  this  loop  was  applied  by  the 
instrument  and  arranged  round  the  pedicle  by  the  fingers ;  the  liga- 
ture is  arranged  in  the  same  way  when  de  Graefe's  serre-noeud  is  used 
or  any  analogous  instrument  of  larger  size  to  grasp  the  pedicle  and 
increase  the  constriction  day  by  day.  Desault  used  two  separate 
cannulse ;  one  end  of  the  ligature  was  passed  into  one  of  the  cannulse^ 
the  other  end  was  held  by  the  double  half  ring  at  the  end  of  a  stylet 
passed  into  the  second  cannula  which  could  be  closed  or  opened  at 
will ;  the  extremities  of  the  two  cannulse  united  by  the  loop  being 
applied  to  the  pedicle  of  the  polypus,  one  was  held  fixed  whilst  the 
other  was  passed  round  the  pedicle  till  meeting  again  with  the  former, 
it  had  completely  surrounded  the  pedicle  by  the  ligature.  By  rotat- 
ing the  two  cannulse  the  ligature  was  twisted  and  detached  from  the 
tubes,  when  the  two  ends  were  passed  through  a  serre-noeud ;  Niessen 
used  two  long  separate  silver  cannulse  with  which  the  ligature  could 
be  passed  round  the  pedicle  of  the  polypus,  after  which  they  were 
held  together  side  by  side  so  as  to  allow  the  two  ends  of  the  liga- 
ture to  be  tightened.  Two  gutta-percha  catheters  ^  may  be  substi- 
tuted for  ]Niessen''s  double  cannula,  or  two  needles  ^  a  quarter  of  a 
yard  long  may  be  used,  the  eyes  serving  to  carry  the  constricting 
ligature  to  the  necessary  depth.  Lastly,  we  may  like  Mayor  employ 
two  or  three  stems  of  steel  or  whalebone  terminating  in  a  claw. 

The  methods  of  constriction  are  as  various.  Levret,  after  having 
tightened  the  loop  as  much  as  possible,  tied  the  two  ends  of  the  liga- 
ture to  the  rings  at  the  outer  end  of  his  double  cannula,  which  he 
then  rotated  so  as  to  twist  the  ligature  on  a  level  with  the  pedicle. 
Desault,  after  having  detached  the  two  ends  of  the  hgature  united 
them  in  one  cord  which  he  passed  through  the  opening  of  a  very 
simple  serre-noeud  (a  steel  stem,  one  extremity  of  which  is  bent  at 
right  angles  and  pierced  with  a  circular  hole,  the  other  being  also  bent 
at  right  angles  like  the  first  in  order  to  hold  the  terminal  extremity  of 
the  hgature  passed  into  the  upper  ring) ;  Sotto^s  serre-noeud  has  been 
substituted  for  this.  Niessen  united  his  tubes  by  passing  them  into  a 
short  double  nozzle  similar  to  a  portion  of  Levret's  double  cannula  i 

'  Bevue  medico-chirurg.,  1851,  p.  89. 

"^  Favrot,  Revue  med.-chirurg.,  Jan.,  1848. 

"^  Hiilin,  Memoires  de  vied,  et  de  chir.  pratiqiies.  Paris,  1862. 


POLYPI    AND    MOLES 


681 


Gooch  introduced  the  two  tubes  simultaneously  into  two  double 
metallic  rings  united  by  a  single  stem.  Bowman  adapted  a  rack  to 
the  extremity  of  this  little  apparatus ;  De  Graefe's  screw  serre-noeud 


Tig.  375. 


Fig.  372.        Fig.  373.       Fig.  374. 
Fig.  372. — Sotto's  serre-noeud. 

373. — Poi-te-lig^ature.     a,  holder;  c,  united  in  a  serre-nceiid  with  screw  d, 


Fig. 


invented  to  apply  the  ligature  round  the  pedicle  and  to  efEect  constriction ; 

this  instrument  may  he  substituted  for  those  of  Levret,  Niessen,  Gooch, 

Bowman  and  Graefe. 
Fig.  374. — Graefe's  serre-nceud  with  perforated  ivory  balls. 
Fig.  375. — Gooch's  apparatus  modified  by  Courty  for  the  application   of   the 

elastic  ligature.    //,  india-rubber  tube  ;  tn,  metallic  guide,  by  means  of 

which  the  india-rubber  ligature  is  passed  through  the  metallic  tubes  tt; 
a  a  a,  rings  and  iron  stem,  into  which  the  tubes  are  adjusted  ;  t  r,  rack, 

of  no  use  when  the  elastic  ligature  is  applied  :  the  two  ends  of  the  india'- 

rubber  tube  are  fastened  to  it. 

and  the  other  instruments  of  the  same  kind  by  which,  when  the  ends 


682 


UTERINE    DISEASES    IN    DETAIL 


of  the  ligatures  are  once  fixed,  constriction  may  be  slowly  and  pro- 
gressively increased  are  usually  preferable.  I  generally  employ  the 
elastic  ligature,  the  loop  of  which  is  applied  round  the  pedicle  by 
Emmet^s  porte-ligature  or  porte-chain,  the  ends  being  passed  by 
means  of  my  metallic  guide  through  two  Gooch's  tubes  brought  close 

together  and  held  by  double  metallic 
rings.  The  elasticity  of  the  elastic 
tube  or  ligature  when  once  fastened 
to  the  rack  at  the  end  of  this  appa- 
ratus is  sufficient  to  keep  up  the  con- 
striction and  produce  ulceration  of  the 
pedicle. 

The  ligature  may  cause  immediate 
or  subsequent  accidents.  The  most 
serious  primary  accident  is  constric- 
tion of  the  uterine  wall  resulting  from 
the  application  of  the  ligature  above 
the  insertion  of  the  polypus  ;  but  this 
is  easily  avoided  with  a  little  care  if  we 
remember  that  it  is  useless  to  apply 
constriction  at  the  point  of  insertion 
of  the  pedicle,  and  that  it  is  even 
better  to  run  the  risk  of  leaving  a 
portion  of  the  tumour;  this  portion 
usually  mortifies  and  falls  of  itself  like 
the  end  of  the  umbilical  cord  included 
between  the  ligature  and  umbilicus. 
— The  drawbacks  resulting  from  mor- 
tification of  the  tumour,  foetid  dis- 
charges, purulent  absorption,  &c., 
have  been  very  much  exaggerated  and 
may  be  generally  avoided  by  frequent 
detersive  lotions,  by  more  rapid  con- 
striction of  the  hgature  or  by  complete 
and  instantaneous  division  of  the  pedicle  below  the  ligature. 

6.  Linear  ecrasement. — This  is  preferable  when  the  polypus  is  very 
vascular.  I  have  performed  it  frequently  and  always  successfully. — 
Lerpiniere,^  L.  Boyer  and  Pajot  suggested  dividing  the  pedicle  of  the 
polypus  by  sawing  it  through  by  alternate  movements  in  opposite 
directions  communicated  to  the  extremities  of  a  metallic  loop  or  thread 
of  whipcord  passed  round  the  pedicle. — Chassaignac^s  instrument  is 
undoubtedly  preferable  to  the  latter  method ;  a  straight  or  curved  in- 
strument is  used  according  to  the  case.  I  think  it  is  usually  easier  to 
pass  a  silk  cord  or  metallic  wire  round  the  pedicle^  than  the  chain  of 

1  Journal  des  connaissances  mSd.-cliir.,  1834. 

^  To  obviate  this  difficulty  Sims  has  invented  a,  portet-chain  (op.  cit.,  pp.  79, 
80,  81,  figs.  28,  29,  30),  and  Emmet  has  devised  a  still  simpler  way  of 
adjusting  the  chain  by  means  of  a  loop  of  thread  carried  to  the  end  of  the 
vagina  by  the  terminal  ring  of  a  long  stylet  (see  fig.  376). 


Fia.  376. — Emmet's    porte-chain 
round  the  pedicle  of  the  tu- 


POLYPI    AND    MOLES 


683 


the  ecraseur,  and  as  the  extremities  of  this  h'gature  may  be  attached 
to  a  good  serre-noeud  and  the  constriction  increased  as  rapidly  as  is 
desirable^  so   as  to  divide  the  pedicle  in  the  same  way  as  with  the 


Fig.  377.  Fig.  378.  Fig.  379. 

Fig.  377. — Sen-e-nceud  for  effecting  section  of  the  pedicle  by  extemporaneous 


Pig.  378. — Chassaignac's  straight  and  curved  linear  ecraseurs. 
Fig.  379. — Section  of  the  pedicle  of  a  uterine  polypus  by  Chassaignac's  curved 
linear  ecraseur. 


Fig.  380. — Aveling's  polyptrite  :  c,  hook  of  the  female  blade ;  a,  b,  male  blade. 

ecraseur,  I  think  this  method  (called  by  Maisonneuve  extemporaneous 
lif/ature)  is  preferable  to  ecrasement  in  such  cases. — The  difficulties  of 
introducing  the  chain  of  the  ecraseur  suggested  to  Aveling^  the  idea  of 
a  new  instrument  composed  of  a  kind  of  pliable  grooved  hook,  in  the 
concavity  of  which  the  pedicle  of  the  polypus  may  be  seized  and  after- 
wards crushed  by  compressing  it  more  and  more  strongly  by  means  of 
a  bent  stem  moved  by  a  vice;  this  instrument  is  called  a, polj/piriie. 

7.  Excision. — This  is  the  quickest  method.  It  has  been  adopted 
by  almost  all  surgeons,  especially  for  fibrous  polypi,  ever  since  Dupuy- 
tren  showed  its  advantages  and  innocuity  (out  of  200  cases  serious 
hsemorrhage  only  occurred   twice),    and   since    Siebold^  and   Mayer^ 

^   Transactions  of  the  Obstet.  Soc,  vol.  iv. 

2  Frauenzhnmcrkrankheiten . 

^  Dissertatio  de  polypis  uteri.     Berlin,  1821. 


684 


UTEEINE    DISEASES    IN    DETAIL 


publislied  an  account  of  the  success  of  their  cases.^  The  facility  of  the 
operation  varies  greatly  according  to  whether  the  polypus  has  descended 
into  the  vagina  or  is  retained  in  the  Momb,  whether  it  is  of  small  size, 
allowing  of  its  being  encircled  by  the  finger  as  a  guide  to  the  bistoury, 
or  so  large  that  it  can  only  be  detached  from  the  uterus  after  being 
drawn  down  or  divided  into  several  fragments. 


Fig.  381.  Fig.  382.  Fig.  383.  Fig.  384 

Fig.  381. — Chassaignac's  tenaculum  hook  forceps  with  concave  hlades. 
Fig.  382. — Greenhalgh's  sliding  tenaculum  hook  forceps. 
Fig.  383. — Eobert's  tenaculum    hook  forceps  with    independent    blades    and 

movable  teeth. 
Fig.  384. — McClintock's  screw. 

Means  of  prehension  are  applied  generally  to  the  periphery  of  the 
tumour.  If  the  polypus  is  easily  torn  it  may  be  better  to  seize  it 
with  polypus  or  ovum  forceps ;  if  it  is  hard  or  sufficiently  resistant  it 
is  better  to  employ  tenaculum  hooks,  either  hooks  with  a  handle  and 

1  It  must  not  be  forgotten  that  excision  is  not  exempt  from  accidents 
common  to  all  operations.  Simpson  has  seen  tetanus  supervene  {Gaz.  hebdoin., 
1854,  p.  686). 


POLYPI    AND    MOLES  685 

of  which  the  claws  may  be  concealed  or  opened  at  will,  and  the  number 
of  which  may  be  multiplied  according  to  necessity  round  the  tumour ; 
or  Museux^s  straight  or  curved  tenaculum  hook  forceps;  or  Chas- 
saignac's  tenaculum  hook  forceps  with  strong  teeth  and  concave  blades ; 
or  Greenhalgh's  sliding  forceps,  the  blades  of  which  can  be  made  to 
seize  the  tumour  at  difPerent  heights  right  and  left ;  or  Robert's  strong 
forceps  with  movable  teeth,  which  can  penetrate  the  tumour  and  be 
detached  from  it  at  will. — When  it  is  impossible  to  encircle  the  tumour 
other  means  of  prehension  may  be  resorted  to  :  for  example,  piercing 
the  accessible  portion  of  the  tumour  with  a  curved  needle  carrying  a 
cord,  by  traction  on  the  two  extremities  of  which  the  polypus  may  be 
drawn  down  and  fixed  ;  or  Lucres  extractor,  a  kind  of  tenaculum  hook 
with  a  handle,  the  diverging  points  of  which  cannot  be  detached  from 
the  tumour  after  they  have  penetrated  it ;  or  lastly  the  ingenious  in- 
strument in  the  form  of  a  screw  or  corkscrew  invented  by  McClintock,^ 
which  is  useful  in  extracting  hard  polypi. 

Instruments  of  section  are  also  very  numerous.  Lobstein  adopted 
the  idea  of  Fabrice  d'Aquapendente,  and  invented  cutting  spoons  or 
scoops.  Mikschik  invented  a  kind  of  ring  ending  in  a  sharp  blade,  to 
be  placed  on  the  end  of  the  index  finger,  allowing  the  pedicle  of  the 
polypus  to  be  cut  as  with  the  nail.  Richerand  used  special  scissors ; 
Siebold  and  Mayer  scissors  with  blunt  points  and  bent  in  the  form  of 
an  S.  Usually  simpler  instruments  suffice  :  a  long  curved  probe- 
pointed  bistoury,  or  long  scissors  with  a  more  or  less  marked  terminal 
curvature  or  with  excentric  articulation,  or  the  curved  hook  with  con- 
cealed blade- invented  by  Simpson  under  the  name  of  polypotome.^ 
The  instrument  is  applied  to  the  pedicle  guided  by  the  index  finger  of 
one  hand,  and  the  tissue  connecting  the  polypus  with  the  uterus  is 
divided  by  repeated  small  incisions  till  the  tumour  is  completely  sepa- 
rated. The  operation  is  more  difficult  when  the  polypus  is  contained 
within  the  uterus.  Herbiniaux^,  being  unable  to  separate  a  polypus  by 
ligature,  was  the  first  to  perform  section  of  the  pedicle  in  the  uterus ; 
but  the  tumour  had  passed  the  cervix  and  had  descended  into  the 
vagina.  Dupuytren  taught  that  the  cervix  should  be  divided  by  a 
puncture  from  without  inwards  when  there  is  question  of  excision  of 
a  polypus  contained  within  the  uterus,  and  that  even  the  vulva  may 
be  incised  when  extraction  cannot  otherwise  be  made  :  he  disapproved 
of  the  previous  use  of  dilators,  which  I  on  the  contrary  feel  bound  to 
recommend  associated  with  ergot :  in  such  cases  the  rules  should  be 
followed  which  I  have  laid  down  when  describing  the  extraction  of 
submucous  fibroids,  their  spontaneous  enucleation  and  their  pedicuiisa- 
tion  in  the  uterine  cavity. 

Adhesions    of    the    tumour    to    the  vagina    or    pseudo-pedicles* 

'  Diseases  of  Women,  p.  71. 

^  For  figures  of  Simpson's  polypotome  and  the  various  tenacuhim  hooks 
made  by  Aubry,  Collin,  Mathieu,  &c.,  see  Trousse  gynecologique  by  Courty, 
p.  37,  and  following.  Paris,  1878. 

'  Parallhle  des  differcnts  instruments  pour  le  traitement  des  polypes  de  la 
matrice,  p.  107.  The  Hague,  1771. 

■*  Berard,  Arch.  c/dn.  de  med.,  t.  ii,  p.  88. 


686  UTERINE   DISEASES   IN    DETAIL 

may  increase  the  difficulties  of  extraction  and  necessitate  fresh 
excisions  which  are  not  without  danger.  Another  peril  may  arise 
from  inversion  of  the  uterus,  which  we  should  beware  of  pro- 
ducing by  too  strong  traction,  and  the  fatal  consequences  of  which  will 
be  avoided  by  following  the  rules  laid  down  in  the  case  of  fibrous 
bodies  for  distinguishing  the  tissue  of  the  tumour  from  that  of  the 
uterus  and  for  avoiding  section  of  the  latter.  Lastly,  the  excessive 
size  of  the  polypus  may  give  rise  to  special  indications.  There  may  be 
disproportion  between  its  diameters  and  those  of  the  vulva  or  even  of 
the  outlet.  In  such  cases  there  are  only  two  courses  to  take :  1,  to 
make  an  incision  in  the  vulva  behind,  towards  the  perinseum  as 
Dupuytren  did,  or  two  lateral  incisions,  as  advised  by  Dubois  in  cer- 
tain cases  of  dystocia;  2,  to  diminish  the  size  of  the  tumour,  which  is 
better ;  this  latter  result  is  obtained  by  first  incising  the  envelope  of 
the  polypus  and  afterwards  enucleating  it ;  or  by  separating  a  cunei- 
form^ segment  of  it  and  bringing  the  two  remaining  halves  together; 
or  by  removing  the  tumour  piecemeal,  as  one  does  the  foetus  in 
embryotomy. 

Subsequent  treatment. — After  extraction  of  the  polypus,  if  there  is 
haemorrhage  it  may  be  arrested  by  injections,  styptics  and  plugging. 
The  patient  should  be  confined  to  bed  in  a  posture  of  semi-fiexion, 
pain  being  alleviated  by  the  use  of  narcotics  in  various  forms,  and  the 
impoverished  constitution  restored  by  the  use  of  tonics,  bark,  iron,  good 
wine  and  generous  diet. 

Eecovery  is  so  speedy  that  it  is  usually  difficult  to  prevent  patients 
from  rising  too  soon :  they  should,  however,  be  kept  in  bed  for  a  week 
or  even  a  fortnight. 

The  origin  of  polypi  shows  that  these  tumours  are  liable  to  return. 
Although  recurrence  is  not  common,  it  has  been  frequently  observed,^ 
therefore  patients  should  be  watched.  When  pregnancy  and  labour 
are  complicated  by  the  presence  of  a  polypus  I  recommend  expectation 
lest  haemorrhage  should  follow  excision.  The  reader  may  be  referred 
to  the  precepts  already  laid  down  for  the  treatment  of  fibrous  tumours 
in  similar  circumstances. 

2.    Uterine  Moles 

Moles,  false  germs,  degenerated  germs,  are  always  degenerations  of 
one  or  other  of  the  principal  portions  of  the  membranes  of  the  ovum 
which  are  destined  to  envelope  the  embryo  and  to  serve  for  its  protec- 
tion and  nutrition.^  They  result  from  two  causes  :  1,  from  the  death 
of  the  germ  or  embryo,  the  body  of  which,  being  macerated  and  dis- 
solved in  the  waters  of  the  amnion,  is  absorbed,  leaving  no  other  trace 

^  Velpeau  and  Chassaignac,  Bulletin  de  la  Societe  anatomique,  1833,  p.  113. 
The  uterus  was  momentarily  inverted,  but  was  reduced  spontaneously. 

^  Braxton  Hicks  mentions  three  cases  of  recurrence  out  of  forty-two  cases 
{Chiy's  Hospital  Reports,  3rd  series,  vol.  xiii,  p.  128,  1868). 

^  Murat,  Diet,  des  Sciences  medicales,  art.  Mole,  1819. — Mme.  Boivin, 
Nouvelles  recherches  sur  I'origine,  la  nature  et  le  traitement  de  la  mile  vfsi- 
cidaire.  Paris,  1827. — Granville,  Ilhistrations  of  Abortion,  ISM. — Cruveilhier, 
Anat.  patliol.,  liv.  i  and  xvi. 


POLYPI  AND  MOLES  687 

than  a  fragment  of  the  umbilical  cord ;  2^  from  the  plastic_,  nutritive 
and  hypertrophic  tendency  with  which  the  appendages  of  the  embryo 
are  endowed  independently  of  the  impulse  conveyed  to  them  by  the 
germ.  The  plastic  tendency,  ni8us  formativus,  being  developed  to  the 
highest  degree,  may  persist  even  after  the  death  of  the  embryo,  even  in 
the  transitory  organs  which  constitute  its  apparatus  for  absorption 
and  nutrition.  The  energy  and  persistency  of  this  tendency,  diverted 
from  the  young  being  that  no  longer  exists,  are  transferred  to  its 
appendages,  which  continue  to  preserve  their  normal  intimacy  of 
connection  with  the  uterus,  and  the  faculty  of  absorbing  and  assimi- 
lating nourishment,  and  which  from  that  time  turn  to  their  own 
profit  the  materials  of  nutrition  intended  for  the  embryo.  Hence  the 
hypertrophic  and  progressive  but  at  the  same  time  irregular  and  terato- 
logical  evolution  which  the  various  embryonic  envelopes  undergo  at 
some  point  or  another.  When  this  evolution  takes  place  in  the  pla- 
centa or  in  the  superimposed  elements  of  the  various  membranes,  sepa- 
rated it  may  be  by  interstitial  clots,  it  gives  rise  to  a  fleshy  mole ;  if  it 
goes  on  in  the  villi  of  the  first  chorion  or  allautois,  with  or  without  par- 
ticipation in  its  vascular  ramifications,  the  hydatidiform  mole  is  pro- 
duced (wrongly  attributed  to  the  production  of  hydatids).  This  origin 
sufficiently  justifies  the  names  oi false  germs,  degenerated  germs,  by 
which  these  moles  have  been  designated. 

1.  The  fleshy  mole  differs  in  appearance  according  to  the  time  at  which 
it  is  expelled.  It  varies  in  size  from  that  of  an  egg  to  that  of  a  child's 
head.  When  expelled  shortly  after  the  death  of  a  very  young  embryo,  it 
preserves  the  form  of  an  egg  with  or  without  the  debris  of  the  embryo  in 
its  cavity ;  this  is  the  false  germ^  of  Boivin  and  Duges  ;  when  expelled 
long  afterwards  it  has  the  appearance  of  a  more  or  less  hypertrophied 
placenta.  Should  the  amniotic  fluid  not  have  escaped  before  the  expulsion 
of  the  mole,  the  size  of  the  tumour  is  larger,  its  tissue  often  gorged 
with  blood,  its  central  cavity  visible  and  filled  with  serum  ;  if  this  fluid 
has  escaped  beforehand  the  tumour  is  harder,  the  cavity  narrower, 
sometimes  filled  with  effused  blood  or  with  clots  arranged  in  successive 
layers,  at  other  times  containing  fragments  of  the  fcetus^  bones,  hair  or 
some  trace  of  the  umbilical  cord ;  the  surface  of  the  mole  may  be  en- 
crusted with  calcareous  salts.  These  moles  must  not  be  confounded 
with  simple  clots  or  fibrinous  concretions  formed  in  the  uterine  cavity. 

2.  The  vesicular  or  hydatidiform  mole  is  a  kind  of  dropsy 
of  the  villi  of  the  chorion.  The  clusters  are  only  ramifications  of 
chorial  or  placental  villi,  the  subdivisions  of  which  are  dilated  space  by 
space  without  the  vesicles  communicating  with  each  other.  This 
increase  of  the  vesicles  and  their  distension  with  serum  is  due  to  the 
fact  that,  after  the  death  of  the  embryo,  the  chorion  continues  to 
receive  materials  for  nutrition  from  the  uterine  decidua  in  such  propor- 
tions that  the  size  of  the  expelled  mass  may  be  very  considerable.  The 
size  of  each  vesicle  varies  from  that  of  a  millet  seed  to  a  pigeon^s  ^^^g. 
The  entire  mole  often  escapes  surrounded  by  the  thickened  decidua. 

^  Op.  cit.,  t.  i,  p.  276. — Courty,  Mecanisme  dc  I'avortement.  Montpellier, 
1860,  and  Montpellier  viedical,  1860. 


688  UTERINE    DISEASES   IN   DETAIL 

Diagnosis. — Moles  often  present  symptoms  of  pregnancy.  The 
patient  believes  at  first,  and  with  reason,  that  she  is  pregnant.  After 
some  time,  whether  the  embryo  dies  owing  to  haemorrhage  from  the 
chorion  or  placenta  and  sanguineous  effusion  between  the  membranes 
of  the  ovum,^  or  whether  the  membranes  are  torn  as  a  consequence  of 
dropsy  of  the  amnion,  sanguineous  efi'Qsion,  or  any  other  morbid  con- 
dition of  the  ovum,  there  may  occur  a  discharge  of  amniotic  fluid, 
mucus,  blood,  or  expulsion  of  the  fragments  of  the  ovum  or  embryo ; 
or  it  may  happen  that  the  patient  has  not  observed  the  escape  of  any 
fragments  coming  from  the  product  of  conception  or  from  the  elements 
contained  in  the  uterus.  However  that  may  be,  the  symptoms  of 
pregnancy  gradually  disappear  or,  on  the  contrary,  even  when  haemor- 
rhage has  occurred  and  the  patient  believes  she  has  aborted,  these 
symptoms  continue  indefinitely  without  the  size  of  the  uteras  and 
abdomen  increasing  in  proportion  to  the  length  of  time  which  has 
elapsed  since  conception.  Therefore  the  duration  of  abdominal  tume- 
faction symptomatic  of  pregnancy  beyond  the  ordinary  term  of  gesta- 
tion, the  irregular  form  of  the  belly,  the  disproportion  between  the 
size  of  the  tumour  and  that  which  the  abdomen  ought  to  have  at  that 
period  of  pregnancy,  the  absence  of  fcetal  movements  and  cardiac 
sounds  combined  with  the  appearance  of  the  presumptive  signs  of 
conception  and  pregnancy  at  the  commencement  of  the  malady  : 
such  are  the  principal  elements  of  a  differential  diagnosis  be- 
tween pregnancy  and  the  presence  of  a  mole  in  the  uterus. 
Amongst  the  most  frequent  symptoms  which  I  have  noticed  are : 
vomiting,  great  debility,  leucorrhoea,  foetid  sero-purulent  discharge, 
oedema  of  the  feet  (seven  times),  great  anaemia  (five  times),  metror- 
rhagia (forty-one  times),  and  internal  metrorrhagia  followed  by  death 
(once).  In  9  cases  the  development  of  the  uterus  was  not  in  propor- 
tion with  the  period  of  pregnancy."  After  some  time  the  symptoms  of 
pregnancy  gradually  disappear,  being  replaced  by  those  characteristic 
of  uterine  polypi.  We  must  remember  that  in  double  pregnancies 
one  embryo  may  be  replaced  by  a  mole,  or  that  a  uterus  containing  a 
mole  may  exceptionally  become  the  seat  of  another  conception  or  of  a 
kind  of  superfoetation.  In  these  cases  the  expulsion  of  the  foetus 
almost  always  occurs  before  the  end  of  pregnancy,  the  mole  being 
expelled  either  simultaneously  or  afterwards.^  Fourteen  times  the  mole 
has  been  found  in  the  os  at  the  moment  of  delivery ;  in  seven  cases  a 
portion  of  the  mole  was  discharged,  four  times  shortly  before  delivery, 
three  times  several  v^eeks  previously ;  six  times  a  foetus  was  present ; 
twice  there  was  double  pregnancy ;  once  there  was  a  placenta  as  well  ; 
four  times  there  was  multiple  pregnancy.  Lastly,  the  expulsion  of 
the  mole  may  occur  from  the  third  to  the  fifth  month,  usually  before 
the  end  of  pregnancy,  but  sometimes  it  occurs  later.     Madame  Boivin* 

^  Courty,  Mecanisme  de  I'avortement  dans  les  premiers  mots  de  la  grossesse, 
Montpellier  viedicale,  1860,  p.  215. 

^  Hayem,  Revue  des  Sciences  medicales,  1873,  p.  734. 

^  Fabrice  de  Hilden,  cent,  ii,  ohs.  52. — Duges  and  Boivin,  op.  cit.,  p.  279. 

"  Op.  cit.,  p.  288. 


TUBEECLE  689 

mentions  a  case  of  this  kind  in  which  the  expalsion  took  place  twelve 
and  a  half  months  after  conception ;  while  some  moles  have  remained 
in  the  uterus  for  several  years.  The  weight  of  a  mole  may  vary  from 
i  lb.  to  6  lbs. 

Treatmerit  consists  almost  exclusively  in  the  extraction  of  the  mole. 
We  should  wait  till  uterine  contraction  or  haemorrhage  occurs.  Some- 
times nature  herself  effects  the  expulsion  of  the  organic  product  and 
there  is  a  true  dehvery  of  the  mole.  If,  however,  there  is  haemor- 
rhage and  other  serious  symptoms  we  may  have  to  induce  expulsion : 
hemostatics,  plugging^  dilatation  of  the  cervix  by  sponge  tents  and 
the  administration  of  ergot  excite  uterine  contractions  and  provoke 
spontaneous  expulsion.  When  this  expulsion  is  not  effected,  or  only 
produced  incompletely  or  too  slowly,  if  the  mole  is  adherent  to  the 
uterine  tissue  it  should  be  extracted  without  delay.  The  same  instru- 
ments are  used  for  this  purpose  as  in  cases  of  soft  polypi,  the  best 
being  Levret's  ovum  forceps.  Care  must  be  taken  to  remove  the 
whole :  after  extraction,  the  same  care  is  necessary  as  after  delivery  : 
rest,  tonics,  generous  diet,  iron  (if  there  is  impoverishment  of  blood), 
ergot  and  hydropathy  (if  indicated  by  softening,  defective  involution, 
the  persistence  of  hypertrophy  or  chronic  congestion  of  the  uterus)  ; 
such  is  the  treatment  required. 


Tubercle 

Tubercular  disease  of  the  uterus  and  its  appendages  is  probably  the 
rarest  disorder  of  these  organs,  the  least  easy  to  diagnose  and  the  most 
difficult  to  cure.  In  fact  the  tubercular  diathesis,  which  so  frequently 
manifests  itself  in  the  lungs  and  other  organs,  so  seldom  attacks  the 
female  genital  organs  that  cases  of  real  tubercle  confirmed  by  autopsy 
may  be  counted.  I  have  collected  4  cases  of  general  tuberculisation 
of  the  genital  organs  diagnosed  during  life  and  verified  by  autopsy  : 
1  of  tubercular  disease  confined  to  the  ovaries^  especially  to  the  right 
ovary,  coinciding  with  pulmonary  tubercle;  2  of  utero-ovarian  tuber- 
culisation, also  coinciding  with  pulmonary  tubercle  ;  in  one  of  these 
latter  patients  tuberculo-purulent  products  had  been  expelled  from 
the  uterus  on  several  occasions  during  the  latter  months. 

It  is  remarkable  that  these  alterations  are  sometimes  manifested 
from  childhood.  Talamon  {Amiales  de  Gijnecologie,  t.  ix,  p.  416. 
Paris,  1878)  has  mentioned  a  case  of  ovarian  tuberculisation  with 
tubercular  pelvic  peritonitis  and  suppurative  and  encysted  metritis 
in  a  child  of  6  years  old.  The  ovaries  as  well  as  the  uterus  may  be 
attacked  by  tubercle ;  only  they  are  perhaps  less  frequently  attacked 
primarily  :  judging  from  the  cases  which  I  have  collected,  it  is  seldom 
that  they  alone  are  attacked.  The  case  is  different  with  the  Fallopian 
tubes:  they  may  be  tubercular  to  the  exclusion  of  other  organs,  and 
although  I  cannot  agree  with  Namias,  Cristoforis  and  Ilokitansky,  that 
the  malady  always  commences  with  them,  I  must  admit  it  very  fre- 
quently does  so.     It  may  be  the  same  with  the  uterus ;  but  it  very 

44 


690  UTEEINE    DISEASES    [N    DETAIL 

seldom  happens  that  this  organ  is  attacked  by  real  tubercle  without  the 
annexes  and  peritoneum  being  affected.  Of  all  portions  of  the  genital 
economy  the  vagina  is  most  seldom  attacked. 

In  these  various  organs^  especially  in  the  tubes  and  uterus,  tubercle 
may  be  met  with  in  a  state  of  crudity,  softening  or  suppuration;  even 
caverns  may  be  met  with :  in  one  patient  there  was  such  a  loss  of  sub- 
stance on  a  level  with  the  recto-uterine  and  vesico-uterine  culs- de-sac 
that  progressive  degeneration  might  have  caused  perforation  of  the 
bladder  and  rectum  had  life  been  prolonged.  The  mucous  membrane 
is  sometimes  softened,  decomposed,  even  detached  by  suppuration  in 
more  or  less  extensive  patches,  laying  bare  the  already  partially  de- 
stroyed fibres  of  muscular  tissue.  The  genital  organs  are  so  seldom 
affected  by  tubercle  that  in  the  immense  majority  of  cases  their  tuber- 
culosis coincides  with  pulmonary  or  general  tuberculisation.  Accord- 
ing to  the  highest  statistics,  those  of  Namias,  tubercle  of  the  genital 
organs  is  met  with  12  times  in  100  phthisical  patients;  in  the  records 
of  the  Institute  of  Pathological  Anatomy  of  Prague,  published  by  Dit- 
trich,  we  find  1  case  of  uterine  tuberculisation  in  40  autopsies  on 
tuberculous  women  ;  Puech  has  only  met  with  3  cases  in  150  autop- 
sies; Cless  of  Stuttgart  1  in  70;  and  as  for  myself  I  have  certainly 
not  met  with  more  than  2  in  100. 

Tuberculisation  of  the  genital  organs  does  not  only  coincide  with 
pulmonary  phthisis,  but  is  also  met  with  in  connection  with  osseous 
lesions,  tubercle  in  the  bones,  articulations^  and  other  organs. 

In  the  numerous  coincidences  just  mentioned  tuberculisation  of  the 
genital  organs  usually  follows  pulmonary  phthisis,  being  the  result  of 
the  serious  alteration  of  nutrition  or  cachexia,  which  often  passes  un- 
noticed amidst  the  general  disorder  of  all  tlie  functions.  It  may, 
however,  precede  it.  Tyler  Smith  has  published  a  case  of  primary 
tuberculosis  of  the  uterus  and  ovaries  followed  by  pulmonary  phthisis 
causing  death.  It  may  even  exist  alone  and  be  discovered  by  autopsy 
at  a  period  in  its  development  when  the  lungs  are  not  as  yet  affected  : 
Siredey^  has  published  a  remarkable  case  of  isolated  tubercle  of  the 
Pallopian  tubes  and  peritoneum ;  Tomlinson^  one  of  tubercle  of  the 
uterus,  tubes  and  ovaries,  with  this  peculiarity,  that  the  uterus  had 
acquired  a  considerable  size  before  the  appearance  of  tubercle  in  any 
other  organ.  In  these  cases  in  which,  contrary  to  the  law  laid  down 
by  Louis,  the  lungs  are  healthy  or  at  least  not  attacked  by  the  morbid 
product,  tubercle  of  the  genital  organs  attracts  the  attention  of  the 
physician  to  the  phenomena  manifested  in  the  pelvis. 

Diagnosis. — It  is  often  ignored,  sometimes  suspected,  seldom  con- 
firmed ;  for  there  are  no  symptoms  which  allow  of  genital  phthisis  being 
diagnosed  with  certainty.'^  It  can  never  be  ascertained  with  certainty 
at  one  visit,  as   Brouardel   has   justly  remarked;    for  of   the  three 

1  Cruveilhier,  Anat.  path.,  iv,  674. — Crocq,  Arch.  gen.  de  mecl.,  1860. 

2  De  la  frequence  des  alterations  des  annexes  de  V  uterus  dans  les  affections 
dites  uterines.     These  de  Paris,  1860. 

3  Ohstet.  Transact.,  1864. 

*  Lebert  [Archivfiir  Gynekologie,  iv,  Heft  3,  1872). 


TUBERCLE  691 

elements  on  which  it  may  be  based,  the  general  condition,  the  local 
state  and  the  course  of  the  disease,  the  latter  is  the  most  important. 

Subjective  sicjns. — The  general  symptoms  are  the  most  prominent, 
the  expression  of  the  face,  the  phthisical  habit  of  the  body,  symptoms 
of  tubercle  in  the  lungs  or  other  organs  coinciding  with  the  local  phe- 
nomena^ vague  pains  in  the  hypogastrium  or  loins,  a  disagreeable  sen- 
sation of  fullness  and  weight  in  the  pelvis  and,  when  the  uterus  is 
enlarged,  frequent  desire  for  micturition,  constipation  alternating  with 
diarrhoea,  difficult  micturition  and  defecation.  From  the  beginning 
menstruation  is  suppressed,  especially  when  the  ovaries  are  affected  or 
atrophied  and  there  is  amenorrhoea,  as  in  the  patients  that  I  have  seen. 
Brouardel  considers  leucorrhcea  to  be  the  prelude  to  the  disease  :  this 
may  be  the  case  if  the  seat  of  the  disease  is  in  the  uterus  and  especially 
in  its  mucous  membrane ;  but  usually  the  peritoneum  is  affected  simul- 
taneously with  the  genital  organs,  or  at  least  is  inflamed  all  round 
them.  Hence  acute  pain,  nausea,  vomiting,  distension,  fever,  &c.,  due 
to  limited  peritonitis  recurring  at  intervals,  to  inflammatory  exacerba- 
tions and  to  attacks  of  acute  inflammation  which  is  grafted  on  to  the 
chronic  phlegmasy.  Lastly,  when  the  malady  progresses  slowly,  invad- 
ing the  whole  of  the  genital  economy,  ascites  is  sometimes  produced. 

Objective  signs. — Palpation  shows  increased  size  of  the  uterus  or  the 
existence  of  a  peri-uterine  tumour,  as  well  as  the  resistance  indicative 
of  chronic  peritonitis :  the  intestines  are  bound  together  by  false 
membranes  and  distended  by  gas. — Digital  touch  reveals  a  displace- 
ment of  the  uterus ;  this  organ  is  carried  out  of  the  axis  of  the  vagina, 
especially  behind,  fixed  and  sometimes  retroflexed.  In  the  vagino- 
uterine  cids-de-sac  we  perceive  inequahties,  nodulations  and  bands  of 
adhesion,  painful  on  pressure  :  small,  rounded,  hard,  non-fluctuating 
nodes  are  observed  on  depressing  these  culs-de-sac,  especially  the  pos- 
terior or  lateral  one,  or  by  rectal  touch. — The  diagnosis  is  somewhat 
facilitated  by  speculum  examination,  which  discloses  cervical  erosions 
and  the  existence  of  a  leucorrhoeal  discharge,  which  may  be  submitted 
to  microscopical  examination. 

Treatment. — The  prognosis  of  this  disease  is  very  serious,  though 
less  so  than  that  of  pulmonary  phthisis :  if  phthisis  is  exceptionally 
curable  tuberculosis  of  the  genital  organs  ought  to  be  more  so,  as  these 
organs  are  not  indispensable  to  life.  The  prognosis  is  probably  also 
less  serious  when  tubercle  is  limited  to  the  uterus  and  there  is  neither 
peritonitis  nor  ascites  :  in  this  case  we  may  hope  to  arrest  the  disease. — 
We  can,  however,  only  treat  the  affection,  having  but  little  direct 
influence  on  its  local  manifestation.  Residence  in  a  warm  climate  and 
in  the  country,  moderate  exercise,  generous  diet,  tonics,  cod-liver  oil, 
preparations  of  iodine,  sulphur  waters  and  sea  bathing  should  be  recom- 
mended. Attention  should  be  paid  to  the  chest,  and  the  digestive  func- 
tions regulated  and  the  strength  supported.  We  must  try  to  prevent 
relapses  by  prescribing  absolute  rest  for  the  genital  economy. 


692  UTERINE    DISEASES    IN    DETAIL 


Cancer 

Under  the  name  of  cancer  I  include  every  disease  characterised 
by  the  double  tendency :  1,  to  destroy  the  tissue  of  the  organ ;  2,, 
to  extend  to  the  neighbouring  organs  more  or  less  rapidly,  whatever 
may  be  the  affections  which  assist  in  the  development  of  this  disease 
or  the  anatomical  forms  which  it  assumes.  The  great  number  of 
women  attacked  by  uterine  cancer  shows  the  importance  of  studying 
the  commencement  of  this  disease.  Out  of  87,348  persons  who  died 
of  cancer  in  England  between  the  years  1847  and  1861,  of  whom 
25,633  were  men  and  61,715  were  women,  there  were  about  3000  cases 
of  cancer  of  the  uterus.^  In  1875,  3640  men  and  7766  women  died 
of  cancer  in  England.^  According  to  Tanchou^  the  relative  pro- 
portions are  2996  cases  of  uterine  cancer  against  1147  cases  of  cancer 
of  the  breast.  Out  of  8500  women  observed  by  Mayer,*  332  were 
affected  with  malignant  tumours,  119  with  cancer  of  the  cervix,  146 
with  cancer  of  the  uterus  and  vagina,  8  with  cancer  of  the  vagina,  10 
with  cancer  of  the  vulva,  2  with  ovarian  cancer,  8  with  mammary  cancer 
and  39  with  cancer  of  organs  not  connected  with  the  sexual  economy. 

Diagnosis. — This  is  especially  difficult  at  the  commencement.  I 
shall  describe  successively  the  signs  of  the  first  period,  those  of  con- 
firmed cancer  and  those  of  the  subsequent  cachexia. 

I.  Uterine  cancel'  at  the  commencement — subjective  signs. — The 
symptoms  which  may  become  presumptive  signs  are  very  equivocal  at 
the  commencement  of  the  malady.  They  ought  to  arouse  the  anxiety 
of  the  physician  who  should  attract  the  attention  of  his  patients  to 
them.     The  local  symptoms  are  pain,  hsemorrhage  and  leucorrhoea.^ 

1.  Spontaneous  pain  and  even  induced  pain  is  often  absent.  Pain 
occasioned  by  walking  is  absent  more  frequently  than  that  produced 
by  coitus,  pressure  and  touch.  This  symptom,  which  becomes  the 
source  of  great  suffering  when  the  cancer  is  in  full  development,  when 
its  ravages  have  destroyed  a  portion  of  the  organ  and  especially  when 
it  makes  itself  felt  anatomically  and  physiologically  by  the  neighbour- 
ing organs,  is  on  the  contrary  absent  at  the  commencement  of  the 
disease  and  even  at  a  period  when  not  only  other  symptoms  have 
attracted  the  attention  of  the  patient,  but  when  direct  examination 
proves  to  the  physician  that  the  most  energetic  treatinent  is  powerless 

^  Simpson,  op.  cit.,  p.  140. 
2  West,  op.  cit.,  p.  367. 

^  Reclierches  sur  le  traitement  medical  des  twmeurs  cancereuses  dii  sein, 
p.  258.  Paris,  1844. 

"  Monatsch.,  1868,  Bd.  xxxii,  S.  245. 

*  According  to  West,  out  of  166  cases  the  first  local  symptom  was  : 
In  30,  pains  of  diJEerent  kinds,  varying  in  intensity. 

„  77,  haimorrhage  usually  profuse  and  without  pain. 

„  23,  lisemorrhage  accompanied  by  pain. 

„  15,  leucorrhoea,  sometimes  infectious,  with  pain. 

,,  21,  leucorrhoea  or  other  discharges  without  pain. 


CANCER  (593 

before  sach  extensive  organic  disease.  I  have  seen  women  only  suc- 
cumb to  uterine  cancer  several  years^  sometimes  seven  or  eight  years, 
after  the  probable  period  of  its  first  development.  I  therefore  regard 
statistics  on  this  point  as  mere  approximations ;  the  average  duration 
of  the  life  of  a  woman  from  the  time  she  is  attacked  by  cancer  of  the 
womb  is  according  to  Lebert^  a  little  more  than  sixteen  months  and 
according  to  West"  a  little  more  than  seventeen  months.  On  the  other 
hand  there  are  cancers  which  run  through  their  several  stages  much 
more  rapidly,  e.g.  in  three  and  a  half  months;  West,  who  gives  them 
the  name  of  acute  cancers,  says  that  he  has  only  observed  these  very 
rare  cases  in  young  women  shortly  after  delivery  or  miscarriage.  I 
have  difficulty  in  accounting  for  the  silence  of  writers  as  to  the  absence 
of  pain  in  the  first  period  of  the  development  of  uterine  cancer.  Many 
have  been  struck  by  the  pains  felt  by  patients  at  the  time  when  they 
were  consulted ;  few  have  inquired  about  the  pains  experienced  before 
this  time.  As  for  myself,  I  have  observed  that  epithelioma  is  usually 
indolent  even  at  an  advanced  period,  and  indeed  till  its  size,  by  caus- 
ing an  increase  of  weight  and  discomfort  in  the  vagina,  a  difficulty  in 
marital  intercourse,  &c.,  produces  a  feeling  first  of  discomfort  and  then 
of  pain  j  but  as  to  these  acute,  darting  pains,  described  as  characteris- 
tic of  cancer,  I  have  never  known  them  appear  till  an  advanced  period 
of  the  disease.  I  have  often  been  consulted  by  women  in  whom  I 
discovered  upon  examination  an  incurable  disease,  death  following 
within  three  months,  and  yet  the  symptoms  were  so  slight  from  the 
absence  of  acute  pain  that  attention  had  never  been  called  to  the 
uterus.  Some  have  been  able  to  continue  marital  intercourse  without 
suffering  and  have  become  pregnant ;  others  have  undergone  great 
fatigue  without  inconvenience.  The  majority  have  continued  to  sleep 
the  whole  night  without  being  awakened  by  pain.  Even  the  most 
characteristic  forms  of  cancer,  scirrhus  and  encephaloid  may  reach  an 
advanced  period  of  their  development  without  having  produced  pain, 
at  least  those  acute,  darting  pains  described  as  characteristic  of  this 
affection.  I  have  seen  a  case  of  scirrhus  which  had  destroyed  the 
posterior  lip  of  the  cervix  and  even  a  portion  of  the  body  of  the  womb, 
reducing  the  patient  almost  to  a  state  of  marasmus,  without  pain 
having  ever  assumed  the  acute  character  supposed  to  be  characteristic 
of  cancer.  Thus  pain,  far  from  being  in  proportion  to  the  gravity  of 
the  disease,  is  frequently  the  reverse,  and  indeed  we  may  boldly  lay 
down  as  an  axiom  in  such  cases  Nimium  ne  crede  dolori. 

2.  Hcemorrliage  is  seldom  absent  at  the  commencement  of  this 
terrible  disease.  Constant  in  internal  and  interstitial  cancer  it  is  even 
usual  in  cancer  of  the  cervix  and  in  the  most  superficial  cancroid 
tumour  of  this  organ. 

At  first  the  loss  of  blood  usually  assumes  the  simple  form  of 
menorrhagia.  This,  however,  is  soon  followed  by  metrorrhagia,  occur- 
ring at  longer  or  shorter  intervals  in  the  intercalary  period ;  these 
haemorrhages  at  last  become  almost  continuous  and  are  so  abundant 

'  Mill,  cancer.,  p.  269. 
-  Op.  cit.,  p.  3y<5. 


694  UTERINE    DISEASES  IN   DETAIL 

that  they  enfeeble  the  patient  and  produce  anaemia.  They  are  arrested 
but  recur  again  till  at  last  they  cease  either  spontaneously  or  under 
the  influence  of  the  general  and  local  hemostatics  that  have  been 
administered. 

3.  Leucorrhoea. — This  symptom  sometimes  precedes  hsemorrhagCj 
frequently  accompanies  it,  follows  it,  and  may  be  considered  a  pre- 
sumptive sign  the  value  of  which  is  greater  than  that  of  hsemorrhage 
owing  to  the  coexistence  or  succession  of  these  two  symptoms.  The 
leucorrhoea  may  be  mucous  when  it  expresses  the  reaction  on  the 
uterine  mucous  membrane  of  cancer  cells  or  cancerous  infiltration  into 
the  muscular  tissue  of  the  womb ;  it  is  more  frequently  serous,  result- 
ing from  the  superficial  exudations  of  a  fluid  on  the  internal  surface 
of  the  body  or  cervix,  the  papillary  or  epithelial  element  of  which 
begins  to  undergo  a  modification,  soon  giving  rise  to  cancroidal  vege- 
tations which  may  be  developed  into  cauliflower  excrescences  projecting 
into  the  vagina.  Serous  in  its  origin  before  the  appearance  of 
haemorrhage,  it  sometimes  preserves  this  character  in  the  interval 
between  these  discharges  of  blood  ;  more  frequently  it  becomes  sero- 
sanguinolent,  sero-purulent,  and  at  last  ichorous.  It  differs  entirely 
from  the  glairy  discharge  of  catarrh,  the  purulent  discharge  of  inflam- 
mation of  the  uterine  mucous  membrane,  and  from  the  muco-purulent 
discharge  which  partakes  of  the  characters  of  the  two  preceding  in 
its  aspect  and  origin.  It  usually  only  becomes  sero-purulent  after  the 
hsemorrhagic  period,  and  ichorous  after  confirmed  disease  has  made 
such  progress  that  ulceration  is  imminent  or  even  declared  at  some 
points.  Whether  partly  sanguinolent  and  partly  purulent  the  loss 
always  assumes  a  very  marked  serous  character ;  it  is  abundant,  stain- 
ing the  linen  like  reddish  water  in  place  of  making  a  spot  like  milk, 
starch  or  yellowish-green  pus.  This  discharge,  as  described  by 
patients  arouses  the  suspicion  of  the  physician ;  it  is  sometimes  very 
acrid,  and  cannot  fail  to  be  an  important  presumptive  sign  at  the  com- 
mencement of  the  disease.  Although  it  may  not  yet  have  acquired  the 
foetid  odour  which  characterises  it  when  ulceration  and  destruction  of 
the  tissues  have  rendered  it  ichorous  and  mingled  with  it  fragments  of 
normal  or  pathological  tissue,  yet  the  absence  of  this  odour,  which 
afterwards  becomes  so  characteristic,  ought  not  to  inspire  the  practi- 
tioner with  false  security. 

General  symptoms  are  usually  slight  or  altogether  absent.  Neither 
digestion  nor  nutrition  is  disordered.  These  functions  are  only  dis- 
turbed when  the  disease,  by  its  extension  and  ulceration,  and  by  the 
inflammation  of  the  neighbouring  tissues  has  reacted  on  the  whole 
economy,  setting  up  fever,  and  revealing  by  undoubted  local  sym- 
ptoms the  existence  of  the  organic  lesion.  Of  all  the  general  sym- 
ptoms, the  first  to  appear  are  usually  sympathetic  nervous  disorders, 
vague  symptoms  of  vital  uneasiness,  hysterical  symptoms,  dragging  at 
the  epigastrium  and  between  the  shoulders,  &c.,  but  it  is  very  difficult 
for  patients  to  suspect  the  nature,  gravity  and  even  the  seat  of  disease 
from  these  symptoms.  I  do  not  think  the  age  and  history  of  the 
patient  are  of  much  help   to  the  practitioner.     The  climacteric  has 


CANCER  695 

been  mentioned  as  a  favorable  age  for  the  development  of  this  malady. 
My  experience  does  not  confirm  this  opinion.  The  most  common 
period  for  cancer  as  for  most  uterine  maladies  is  that  of  sexual 
activity,  between  the  ages  of  thirty  and  fifty.  I  have,  however,  seen 
it  in  young  women  of  twenty  and  twenty-five,  and  in  old  women  of 
sixty  and  seventy.  Nor  must  it  be  thought  that  married  women  alone 
are  subject  to  this  disease,  I  have  frequently  seen  virgins  attacked  by 
it,  but  in  the  latter  the  development  of  cancer  seems  more  frequently 
to  coincide  with  the  approach  of  the  menopause.  As  to  heredity  I 
think  its  influence  is  undoubted  notwithstanding  the  contrary  opinion 
expressed  by  Lebert.^  This  circumstance  should  be  taken  into  ac- 
count not  only  in  reference  to  the  diagnosis  but  also  in  the  prognosis 
and  treatment.  I  have  seen  a  great  many  examples  of  heredity  in 
cancer  of  the  uterus.  Sometimes  it  can  be  traced  to  the  mother, 
grandmother,  aunts  or  sisters  of  the  patient,  and  sometimes  to  the 
father  or  paternal  side  of  the  family.  I  attended  a  patient  for  cancer 
of  the  cervix  in  whom  the  influence  of  heredity  both  as  to  nature  and 
locality  was  remarkably  exemplified :  two  aunts  had  succumbed  to 
cancer  of  the  cervix,  and  the  father  to  cancer  of  the  prostate.  I  am  at 
present  attending  a  lady  suffering  from  advanced  uterine  cancer,  whose 
mother  died  ten  years  ago  of  the  same  disease.  I  have  another 
patient  who  is  almost  in  the  same  condition,  whilst  her  daughter,  aged 
twenty-one,  who  was  only  married  three  months,  having  lost  her 
husband  two  years  ago,  has  suffered  since  her  marriage  from  metritis 
accompanied  by  uterine  granulations. 

Objective  signs. — These  may  enable  us  to  form  a  certain  diagnosis 
from  the  very  commencement  of  uterine  cancer.  The  pain  produced  by 
pressure,  especially  by  the  association  of  palpation  with  digital  touch, 
the  increased  size  of  the  organ,  its  partial  tumefaction  on  one  surface 
or  point,  the  globular  form  of  one  or  more  tumours,  the  multiple  and 
submucous  indurations  of  the  cervix,  or  the  development  of  hard 
resisting  excrescences  which  are  at  the  same  time  friable  and  bleed- 
ing :  the  dilatability  of  the  cervix,  the  appearance  of  its  nodosities,  its 
patches  of  violet  colour  with  vascular  venous  injection  round  them,  or 
the  appearance  of  characteristic  excrescences  of  which  I  shall  speak 
immediately,  are  all  symptoms  which,  when  added  to  those  of  pain  and 
previous  haemorrhage,  of  serous,  or  sero-sanguinolent  discharges,  dis- 
ordered nutrition,  puffiness  of  the  face  or  emaciation,  feverishness,  &c., 
soon  become  certain  signs  of  the  existence  of  cancer  of  the  womb. 

II.  Confirmed  uterine  cancer. — When  cancer  is  confirmed,  or  rather 
when  it  has  reached  the  period  of  ulceration,  doubt  is  no  longer  possi- 
ble. At  this  period  the  general  symptoms  are  considerably  aggra- 
vated. They  vary  in  different  patients;  but  disorders  of  nutrition 
always  occur,  emaciation  follows,  often  accompanied  by  fever.  When 
a  patient  complains  of  pain,  metrorrhagia,  or  serous  leucorrhoea,  we 
may  suspect  the  gravity  of  the  malady  by  merely  feeling  the  pulse :  its 
frequency,  the  dryness  and  heat  of  the  skin,  especially  the  palm  of  the 
hand,  are    alarming    presumptive    symptoms.     Pains,   ichorous    dis- 

'  Op.  cit,,  p.  273, 


Q96  UTEEINE    DISEASES    IN   DETAIL 

charges,  emaciation,  debility,  fever,  the  alteration  of  the  features  and 
colour  of  the  face  leave  no  doubt  as  to  the  existence  and  nature  of  the 
disease ;  we  have  merely  to  ascertain  the  extent  of  it,  and  institute  the 
most  appropriate  treatment  for  arresting  its  progress  and  mitigating 
its  effects. 

During  this  period,  which  may  have  a  rapid  evolution,  although  its 
course  is  usually  slow,  the  constitution  of  the  patient  is  gradually 
imj)aired  by  the  establishment  of  the  cancerous  cachexia  although 
hsemorrhage  has  often  ceased.  There  are,  however,  fungous  cancers 
or  tumours  which  are  developed  rapidly  and  characterised  by  rich 
venous  circulation,  great  friability  and  a  tendency  to  destruction  :  in 
this  case  hsemorrhage  continues  to  recur ;  I  have  seen  cases  in  which 
it  recurred  to  the  very  end,  and  so  abundantly  as  to  determine  great 
anaemia,  hastening  the  end  in  such  a  marked  way  that  death  seemed 
to  be  the  immediate  result  of  the  loss  of  blood.  With  the  exception 
of  these  cases  leucorrhoea  is  the  only  discharge  which  characterises  the 
advanced  period  of  the  disease.  These  discharges  are  reddish,  sero- 
sanguinolent,  ichorous,  fetid,  and  very  abundant,  and  so  characteris- 
tic that  they  enable  the  experienced  physician  to  form  a  probable  if 
not  a  certain  diagnosis  as  soon  as  he  enters  the  room  or  raises  the  dress 
of  the  patient.  The  pain  is  not  less  characteristic ;  in  addition  to  the 
feeling  of  weight  and  discomfort  in  the  pelvis,  aching  in  the  groins 
and  thighs  and  the  pain  produced  by  pressure,  there  is  dull  constant 
suffering  aggravated  at  intervals,  sometimes  increased  to  an  excruciat- 
ing degree.  The  continuity,  nature  and  acuteness  of  the  pain  depend 
on  several  causes. 

The  nature  of  the  tumour  and  especially  its  increasing  size,  its  extension 
to  the  sensitive  organs  whose  functions  it  disturbs,  the  inflammatory 
symptoms  which  it  evokes  in  the  neighbouring  organs  (the  vagina, 
bladder,  rectum,  and  peritoneum),  making  the  performance  of  their 
functions  difficult  if  not  impossible,  preventing  all  exercise  and 
change  of  posture  owing  to  its  extension  as  far  as  the  neurilemma  of 
the  nerves  belonging  to  this  region :  these  are  the  causes  of  those 
exacerbations  of  pain  which  digital  touch  almost  always  produces  with 
significant  intensity.  The  most  serious  local  symptoms  are  then  mani- 
fested, in  consequence  of  the  invasion  and  destruction  of  the  organs 
contained  in  the  pelvis.  The  inflamed  bladder  immovably  fixed 
by  the  invading  cancer  and  compressed  on  a  level  with  the  cervix  can 
no  longer  expel  the  urine  -^  the  patient  requires  to  be  catheter- 
ised,  as  spontaneous  contractions  of  the  viscus  cause  the  most  acute 
pain.  In  the  end  a  vesico-vaginal  or  vesico-uterine  fistula  is  formed 
by  ulceration,  so  that  patients  after  having  experienced  great  diffi- 
culty in  passing  their  urine  find  it  impossible  to  retain  it.  The  same 
phenomena  take  place  in  the  rectum,  the  vagina  becoming  a  cloaca 
in  which  cancerous  ichor  and  uterine  discharges  are  mingled  with 
urine  and  fecal  matters  and  are  discharged  by  the  vulva.     Ulceration 

^  One  of  the  ureters  may  be  invaded,  contracted,  even  obliterated,  and  after- 
wards dilated  above  the  contracted  point,  as  well  as  the  calices  of  the  kidney, 
the  glandular  substance  of  which  atrophies. 


CANCER  697 

of  the  uterine  tissue  may  hasten  the  result  when  the  body  and  especi- 
ally the  fundus   of  the  uterus  is  attacked   by  cancer  :  I  have  seen  a 


Fia.  385. — Cancer  of  the  cervix  extending  to  fhe  bladder,  rectum  and  upper 
portion  of  the  vagina  ;  communication  established  by  ulceration  between 
these  three  organs  :  u,  uterus  ;  v.  vagina  ;  r  r,  rectum  ;  b,  bladder. 

patient  succumb  to  rapid  peritonitis  caused  by  perforation  of  the 
fundus  of  the  uterus ;  another  succumbed  in  a  few  days  to  pelvic 
peritonitis  consecutive  to  a  similar  ulceration  of  the  posterior  wall  of 
the  organ.  Digital  touch  enables  us  to  ascertain  the  progress  of  the 
disease,  its  seat,  and  the  exact  degree  it  has  reached  in  its  destructive 
course.  Sight  confirms  the  information,  but  the  use  of  the  speculum 
is  often  interdicted,  owing  to  the  pain  caused  by  the  introduction  of 
the  instrument  and  the  frequent  impossibility  of  embracing  the  cervix 
or  even  of  discovering  the  orifice,  on  account  of  its  position  behind 
and  of  the  enormous  tumefaction  of  its  two  lips,  and  also  to  the 
facility  with  which  the  tissue  may  be  lacerated  and  give  rise  to  fresh 
hsemorrhage. 

Diversify/  of  seat  and  form  of  uterine  cancer. — It  is  at  the  period 
when  the  malady  is  confirmed  that  we  can  distinguish  the  various 
forms  of  cancer,^  at  least  from  the  symptomatic  point  of  view.  These 
are  the  elements  which  sight,  vaginal  and  rectal  touch,  combined  with 
palpation  and  the  use  of  the  sound,  furnish  for  the  differential  diag- 
nosis of  the  various  forms  of  cancerous  disease. 

*  Ernest  Wagner,  Zre&s  der  Gebarmutter.  Leipsic,  1858. — Cornil,  Des  tumeurs 
epitheliales  du  col  uterin  {Journal  d'Anatoinie  et  de  Physiologie  de  Robin, 
1864).  Scirrhus  and  encephaloid  only  differ  in  the  density  or  rarefaction  of  the 
solid  elements  proportionally  to  the  abundance  of  the  cancerous  fluid  (see  Re- 
cherches  sur  I'histologiedu  cancer,  inmy  CUnique  chirurg.,  p.  59.  Montpellier, 
1851).  Cancroid,  so  nsimed.  by  hehevt  [Physiologic pathologique.  Paris,  1846), 
better  known  by  the  name  of  epilhelioma,  given  to  it  by  Hannover  {Das  Epi- 
thelioma. Leipsic,  1852),  and  under  which  it  has  been  described  by  Paget 
{Lectures  on  Tamours,  vol.  il.  London,  1852),  is  placed  by  Ilouel  (Cruveilbier, 
Anat.  'path,  gen.,  t.  v,  p.  296.    Paris,  1864)  with   fibro-i)lastic  tumours  in  the 


698  UTERINE    DISEASES    IN   DETAIL 

A.  Cancer  of  the  Cervix 

1.  Epithelioma  of  the  vaginal  portion  of  the  cervix. — The  first 
modification  made  in  the  normal  form  and  structure  of  the  cervix  by 
the  development  of  epithelioma  on  its  vaginal  portion  is  the  alteration 
of  its  surface,  which  becomes  irregular,  being  covered  with  numerous 
elevations  irregularly  developed,  situated  like  granulations  round  the 
orifice  or  on  one  of  the  lips,  always  more  on  one  lip  than  the  other 
although  adjoining  the  orifice,  having  the  appearance  of  papillary 
hypertrophy,  affecting  the  epithelial  element  much  more  than  the 
dermis  of  the  papillse  and  presenting  a  striking  analogy  with  epi- 
thelioma developed  on  other  parts  of  the  body,  especially  at  the  natural 
orifices,  the  vulva,  anus,  eyelids,  and  above  all  round  the  mouth,  in 
fact,  with  the  usual  form  of  buccal  and  particularly  labial  cancer. — 
Frequently  it  is  developed  over  the  whole  surface  of  the  cervix,  con- 
tinuing regularly  and  forming  a  large  excrescence  in  the  form  of  a 
cauliflower  like  an  inverted  mushroom,  projecting  in  every  direction 
beyond  the  surface  of  the  cervix  itself,  the  orifice  of  which  is  often 
found  with  difficulty.  Frequently  while  produced  in  the  same  way  it 
invades  the  two  lips  unequally  or  is  only  manifested  on  one  of  them, 
leaving  the  os  uteri  behind  or  in  front  according  to  whether  the  ex- 
crescence is  situated  on  the  anterior  lip,  as  occurs  most  frequently,  or, 
as  is  more  rarely  the  case,  on  the  posterior  lip.  At  this  period  it  is 
important  to  distinguish  epithelioma  from  other  organic  alterations  of 
the  cervix,  such  as  diphtheritic  or  fungous  ulcers,  granulations  and 
vegetations.  This  distinction  is  easy,  for  the  principal  characters  of 
epithehoma  are  :  inequality  of  development  of  the  elementary  and 
secondary  groups,  the  latter  being  more  voluminous  and  formed  by 
the  association  of  epithelial  cells,  which  the  microscope  reveals  as 
essential  elements  of  their  structure ;  compactness  of  tissue,  the  rela- 
tive fragility  of  which  depends  on  this  very  compactness,  hardness  and 
non-elasticity ;  a  tendency  to  bleed  after  the  lacerations  caused  by 
touch ;  if  the  epithelioma  is  not  vegetating,  it  offers  a  characteristic 
aspect ;  hard,  nodulated,  irregular,  vascular  and,  on  microscopical 
examination,  disclosing  to  view  the  epithelial  cells ;  there  is  a  serous 
or  sero-sanguinolent  secretion  from  the  surface  of  the  epithelioma, 
or  there  is  a  purulent  ichorous  secretion  from  the  ulcerated  points  of 

class  of  pseudo-cancers.  It  is  of  little  practical  importance  whether,  after 
Lebert  and  the  French  school,  cancer  is  distinguished  from  cancroid  by  the 
expressions  heteromorphous  and  homceomorphous.  the  former  being  attributed  to 
the  organisation  of  new  elements  in  a  diseased  blastema,  and  the  latter  to 
the  morbid  proliferation  of  normal  epithelial  cells  ;  or  whether,  after  Virchow, 
whose  ideas  have  been  adopted  by  the  German  and  English  schools,  both  of 
these  tumours  are  attributed  to  a  morbid  hyperplasia  of  normal  cells  deviated 
from  their  type  and  urged  into 'a  course  of  pathological  proliferation  by  the 
unknown  cause  which  presides  over  the  development  of  cancerous  affections. 

The  development  of  cancer  in  the  uterus  does  not  exclude  that  of  fibroma 
in  the  same  organ,  tubercle  in  the  lungs  if  not  in  tlie  womb,  nor  of  syphilitic 
chancre  on  the  cancerous  ulcer  itself.  Such  cases  have  been  known,  and  far 
from  neutralising  each  other  these  various  affections  seem  to  concur  to  hasten 
death. 


CANCER  699 

the  tumour,  it  being  seldom  that  some  portion,  some  exuberance,  is  not 
attacked  by  ulceration. 

This  form  of  cancer  if  not  arrested  by  ablation  is  developed  with 
frightful  rapidity.  The  tumour  formed  by  these  excrescences,  the 
various  branches  of  which  press  against  each  other,  presenting  the 
appearance  of  the  vegetable  from  which  they  take  their  name,  soon 
exceeds  the  dimensions  of  an  egg  and  sometimes  acquires  an  enormous 
size,  even  filling  the  cavity  of  the  distended  vagina,  compressing  the 
neighbouring  organs  and  mechanically  hindering  their  functions,  even 
before  it  has  invaded  the  upper  portion  of  the  uterus.  As  a  rule,  how- 
ever, it  gradually  extends  to  other  points;  it  may  even  assume  this 
mode  of  development  altogether,  only  giving  rise  to  slight  excres- 
cences, but  spreading  in  every  direction  over  a  large  surface  all  round 
the  central  excrescence  or  starting-point.  At  first  the  vaginal  portion 
of  the  cervix  is  attacked  and  soon  afterwards  the  vaginal  mucous 
membrane  itself,  behind,  before,  and  on  both  sides ;  the  finger  perceives 
nodules  of  induration  pressed  one  against  the  other  round  the  cervix, 
isolated  a  little  further  on,  often  disseminated  at  a  great  distance,  pre- 
ceding the  excrescences  which  are  soon  developed  on  these  centres  ; 
one  would  say  that  the  cancer  had  spread  its  roots  in  these  different 
directions,  or  they  are  like  suckers  or  seeds  scattered  profusely  near  the 
centre  of  the  disease  and  more  sparsely  further  off.  The  tumour  next 
invades  the  uterine  cavities,  beginning  with  the  cervix  and  ending 
with  the  body. 

Epithelioma  of  the  cervical  cavity  is  less  easy  to  diagnose  as  its 
situation  conceals  it  from  sight.  The  same  circumstance  hinders  its 
development  as  a  vegetating  excrescence,  in  consequence  of  which  it 
may  extend  more  deeply,  either  towards  the  uterine  cavity  or  in  the 
thickness  of  the  muscular  tissue  before  showing  itself  at  the  orifice. 
It  produces  hsemorrhages  and  leucorrhoeal  discharges,  however,  even 
perhaps  at  an  earlier  date;  and,  as  it  tends  to  vegetate,  it  dilates  the 
cervical  cavity,  softens  this  organ  and  presents  itself  at  the  point  which 
offers  the  least  resistance,  i.  e.  the  softened  and  dilated  os,  which  soon 
participates  in  the  progress  of  the  organic  degeneration. 

2.  Parenchimatous  cancer  of  the  cervix,  if  it  is  allowable  thus  to 
name  cancer  which  is  developed  within  the  tissue  proper  of  this  organ, 
especially  in  its  muscular  tissue,  may  also  be  diagnosed  at  an  early 
period  and  more  easily  than  cancer  of  the  body  of  the  womb.  It  is  cha- 
racterised by  increase  of  size  and  heat  of  the  cervix,  by  its  general  in- 
duration, irregularity  and  the  sensation  of  hard,  globular,  often  multiple 
bodies  on  one  of  the  lips  observed  in  the  thickness  of  the  cervix  at  a 
variable  depth ;  there  is  no  resistance  nor  sensation  of  fluctuation,  no 
primary  degeneration  of  the  mucous  membrane  nor  of  its  epidermis; 
but  there  is  a  congestive  condition,  an  unequal  dark  red  coloration,  red 
on  the  projecting  portions,  violet  on  other  parts,  especially  on  the  cir- 
cumference of  the  globular  projections,  and  capillary  venous  injection 
round  these  deep  tumours  or  nodulations  which  are  sometimes  very 
painful  on  pressure  (Fig.  121,  p.  139).  Cancer  developed  in  the 
tissue  of  the  cervix  may  assume  the  form  of  scirrhus  or  encephaloid 


700  UTERINE    DISEASES    IN    DETAIL 

according  to  tlie  density  of  its  tissue^  the  closer  grouping  of  its  ele- 
ments, the  predominance  of  fibres  and  fibro-plastic  elements  over  the 
cancer  cells  or  the  presence  of  a  variable  quantity  of  cancerous  fluid  ; 
but  as  these  forms  when  developed  in  the  uterine  tissue  do  not  present 
different  characters  from  those  which  they  offer  when  developed  in 
other  tissues  I  shall  not  here  give  a  comparative  description  of  them, 
but  merely  make  two  remarks  on  the  subject.  The  first  is  that  scirrhus 
has  seemed  to  me  more  common  than  encephaloid ;  the  second,  that 
when  ulceration  attacks  these  tumours  and  has  a  destructive  tendency 
it  may  cause  as  extensive  destruction  in  scirrhus  as  in  encephaloid. 
I  remember  having  seen  a  young  lady  in  whom  scirrhus  of  the  cervix, 
which  was  easily  diagnosed  by  the  tumefaction  and  hardness  of  the 
anterior  lip  and  of  the  rest  of  the  uterus,  and  which  was  developed 
originally  in  the  cervix,  had  very  soon  extended  to  the  whole  body, 
and  when  attacked  by  ulceration  in  a  short  time  caused  sach  destruc- 
tion that  the  whole  posterior  lip  and  almost  the  entire  posterior  seg- 
ment of  the  uterus  had  disappeared,  allowing  the  finger  to  penetrate 
behind  the  cervix  and  the  anterior  segment  of  the  organ  into  a  vast 
cavity  full  of  ichor  and  cancerous  detritus,  at  the  end  of  which  the 
fundus  of  the  womb  could  be  felt. 

B.   Cancer  of  the  Bodtf  of  the   Uterus^ 

1.  There  is  no  doubt  that  epithelioma  may  be  developed  in  the 
uterine  cavity  on  the  mucous  membrane  of  the  body  as  well  as  on  that 
of  the  cervix,  and  as  on  the  vaginal  portion  of  the  latter  assume 
the  vegetating  form  and  propagate  itself  over  the  whole  womb  to  the 
neighbouring  organs.  Having  ascertained  the  existence  of  the  pre- 
sumptive symptoms  just  described,  direct  examination  by  digital 
touch,  speculum  and  sound  leads  to  a  certain  diaguosis.  In  the  case 
of  cancer  of  the  uterine  cavity,  as  in  that  of  polypi  or  any  other  pro- 
duct developed  in  this  natural  cavity,  contractility  of  the  organ  is 
excited  and  is  manifested  by  expulsive  efforts,  the  effect  of  which  is  to 
tumefy,  soften,  and  dilate  the  cervix.  If  we  take  advantage  of  this 
tendency,  encouraging  it  by  the  introduction  of  dilators,  not  only  may 
the  sound  be  introduced  into  the  uterus  but  the  finger  itself,  the  deli- 
cate sensibility  of  which  discovers  sufficient  elements  for  forming  a 
certain  diagnosis  in  the  inequality  of  the  cervix,  the  fragility  of  the 
tissue,  the  form  of  the  excrescences,  and  the  presence  of  detritus  apart 
from  the  ichor,  a   certain  quantity   of  which  it  brings  away  mingled 

1  Although  cancer  of  the  body  is  undoubtedly  less  common  than  that  of  the 
cervix,  it  is  not  very  rare.  I  have  seen  some  20  cases,  Seyfert  has  seen  5, 
Kiwisch  2,  Dittrich  2,  Lebert  2,  and  Scanzoni  2.  Out  of  429  cases  of  uterine 
cancer  seen  in  the  hospital  at  Vienna,  there  was  only  one  case  of  primary 
cancer  of  the  body.  Saxinger  {Monatsch.,  xxiv,  71)  has  collected  2  cases, 
Simpson  1  {Gaz.  hebdom.,  1854,  p.  389),  Ballard  1  (Provincial  Medic. 
Journal,  May,  1851),  Eecklinghausen  1  {Monatsch.,  xx,  169),  I'orget  {Gaz. 
med.,  1851,  p.  640)  has  published  2  cases  ;  lastly  La  Gazette  des  liiipitaux, 
1861,  p.  208,  has  recorded  3  cases  taken  from  Huguierand  Demarquay's  practice. 
See  also  Pichot,  Jititde  clinique  sur  le  cancer  du  corps  ct  de  la  cavite  de 
I'uterus.  These  de  Paris,  1876. 


CANCER  701 

with  small  fragments  of  epithelioma.  This  examination  should  be 
made  with  great  care,  as  cancer  of  the  cervix  does  not  always  prevent 
pregnancy. 1 

But  when  recent  haemorrhage  and  presumptive  signs  of  cancer  of 
the  body  remove  all  idea  of  pregnancy,  we  may  make  such  an  exami- 
nation in  order  to  determine  whether  it  is  a  case  of  cancer,  uterine 
catarrh,  granulations,  uterine  fungosities,  or  polypi,  because  these 
latter  maladies  are  curable  and  require  prompt  and  active  therapeutical 
treatment.  We  must,  however,  remember  that  if  the  malady  is  ad- 
vanced perforation  of  the  uterus  weakened  by  ulceration  is  to  be  feared 
{see  p.  697). 

3.  Interstitial  or  parenchymatous  cancer,  developed  in  the  thick- 
ness, in  the  interstices  of  the  tissue  proper  of  the  organ  may,  as  has 
been  demonstrated  by  autopsy,  be  either  scirrhus  or  encephaloid ; 
may  be  developed  in  either  of  the  two  walls  before  extending  to  the 
rest  of  the  organ ;  may,  like  fibroids,  increase  towards  the  external 
surface  of  the  uterus  or  towards  its  cavity,  projecting  in  one  direc- 
tion or  another ;  and  may,  lastly,  ulcerate  at  some  point,  especially 
on  the  side  which  looks  towards  the  uterine  cavity.  Apart,  however, 
from  the  general  symptoms  and  from  the  tardy  proof  afforded  by 
products  of  ulceration,  no  symptom  can  be  considered  as  certain  nor 
distinguish  it  positively  from  fibroids,  tuberculous  masses,  or  other 
interstitial  changes  of  the  body  of  the  w^omb.  Besides,  cancer  may 
exist  in  the  uterus  simultaneously  with  tubercle,  pus,  or  fibroids. 
Although,  however,  several  practitioners  have  m"et  with  fibroids  and 
cancer  in  the  same  uterus,  they  have  never  seen  fibroid  bodies  dege- 
nerate into  cancer.2  Only  the  differential  diagnosis  is  more  difificult 
than  the  anatomo-pathological  distinction.  In  such  cases,  therefore, 
we  must  take  into  consideration  the  history  of  the  patient,  heredity, 
general  symptoms,  and  all  the  subjective  signs  which  can  increase 
the  mass  of  evidence,  though  it  may  not  lead  us  to  a  certain  diagnosis 
until  the  disease  has  reached  an  advanced  stage. 

III.  Cancerous  cachexia. — Cancer  invades  the  cervix  from  the  body 
and  vice  versa  ;  from  these  it  extends  to  the  vagina,  bladder,  rectum, 
and  the  fibrous  tissue  interposed  between  these  organs.  The  Fallo- 
pian tubes  and  ovaries  are  affected  less  frequently,  v\diilst  on  the  con- 
trary they  participate  more  often  in  the  extension  of  tubercular  dis- 
ease. The  inguinal  and  pelvic  ganglia  are  seldom  enlarged  in  the 
beginning  but  are  attacked  at  a  later  period,  especially  the  latter,  as 
well  as  the  lumbar  and  mesenteric  ganglia  in  cases  of  considerable 
generalisation  of  these  diathetic  localisations.  The  lymphatic  vessels, 
even  the  thoracic  duct,  may  like  the  ganglia  be  affected  by  the  disease 

'  It  would  soeui  tliat  pre<;'naticy  arrests  the  course  of  cancer,  except  in  the 
cases  in  which  it  terminates  prematurely  b}'  abortion.  But  it  would  also  seem 
that  the  course  of  tlie  disease  recommences  more  rapidly  after  delivery,  hasten 
int^  the  death  of  patients.     See  West,  op.  cit.  p.  409.  London,  18(54. 

'  Cruveilhier,  A\wt.  paih.  grn.,  t.  iii,  p.  ()!)8,  and  t.  v,  pp.  183,  288.  Paris, 
18(>4. 


702  UTEEINE    DISEASES    IN    DETAIL 

or  contain  cancerous  fluid.^  Lastly^  the  neighbouring  veins  are  often 
attacked^  either  from  the  malady  invading  the  tissue,  or  from  the 
transport  of  the  cancerous  fluid  giving  rise  to  malignant  vegetations 
on  their  internal  membrane.^  The  nerves  themselves  do  not  escape 
from  this  propagation.^ 

Cancer  does  not  increase  without  damage  to  the  surrounding  tissues 
and  organs.  The  extension  of  the  tumour  and  the  ulcerative  pro- 
cess which  manifests  itself  simultaneously  determine  the  development 
of  inflammatory  phenomena  not  only  in  the  afiected  organs  but  in 
neighbouring  tissues  within  a  certain  radius^  assuming  different  forms 
according  to  the  nature  of  the  organs  and  tissues.  Por  example,  in 
parenchymatous  and  in  fibrous  tissue,  inflammation  produces  indura- 
tion ;  at  a  later  period  it  may  cause  softening  and,  though  rarely, 
abscesses,  assisting  the  cancerous  ulceration  by  acting  in  the  same 
direction  and  producing  analogous  results.  On  the  surface  of  the 
peritoneum,  on  the  contrary,  it  produces  albuminous,  fibrinous  and 
purulent  exudations  which  give  rise  almost  always  to  adhesions 
between  the  two  contiguous  surfaces  of  this  serous  membrane  which 
help  to  keep  up  displacement  of  the  organs,  to  hold  them  fixed  in 
vicious  positions  and  to  increase  pain  ;  thus  the  folds  of  the  broad 
ligaments  adhere  to  each  other,  the  Eallopian  tubes  or  ovaries  may 
adhere  to  the  uterus,  rectum,  and  intestines,  leaving  between  the  adhe- 
sions winding  cavities  filled  with  serum,  the  last  retreat  of  chronic 
inflammation  of  the  peritoneal  membrane. — Peri-uterine  inflammation 
is  not  the  only  cause'  of  the  immobility  and  pain  ;  the  invasion  of  the 
organs  contained  in  the  pelvis  gives  rise  to  the  formation  of  a  can- 
cerous mass  in  the  period  of  cachexia  which  sometimes  confuses 
together  the  vagina,  bladder  and  rectum,  preventing  the  accomplish- 
ment of  their  respective  functions,  or  what  is  worse  establishing  a 
communication  between  them  so  that  the  vagina  becomes  a  kind  of 
cloaca  common  to  all  the  excretions  (Fig.  385).  Happily  for  the 
patient  the  cachexia  gradually  produces  exhaustion  and  consumption  ; 
when  a  continued  fever,  increasing  in  the  evening  and  assuming  the 
hectic  form,  soon  produces  the  last  stage  of  marasmus  quickly 
followed  by  death. 

Treatment.' — There  is  no  absolute  cure  for  cancer  as  far  as  we  know; 
and  the  relative  curability  of  uterine  cancer  appears  to  depend  on  the 
nature  of  the  malady,  and  on  its  position  in  the  various  parts  of  the 
womb. 

With  regard  to  the  nature  of  cancer  epithelioma  is  evidently  more 
curable  than  scirrhus  and  encephaloid  ;  the  vegetating  form  of  epithe- 
lioma seems  to  me  also  more  curable  than  its  corroding  form,  tuberous 
cancer  more  so  than  ulcerous,  and  dry  more  so  than  moist  cancer. 
Epithelioma,  whether  of  the  uterus  or  lips,  is  usually  less  dependent 

^  Hourman,  Memoire  sur  le  cancer  uterin  (Bevue  med.  frang.  et  Strang., 
1837). — And  Lebert,  Maladies  cancereuses. 

'  Cruveilhiev,  Anat.  path,  du  corps  humain,  t.  ii,  liv.  23,  and  Anat.  path. 
gen.,  t.  v,  pp.  226,  275.  Paris,  1864 

3  V.  Supra,  p.  696. 


CANCER  703 

on  a  general  affection  than  on  an  alteration  of  local  vitality.  There 
are  more  examples  of  labial  epithelioma  successfully  treated  by  opera- 
tion without  return  than  of  scirrhus  or  encephaloid.  It  is  the  same 
with  epithelioma  of  the  cervix ;  I  have  seen  so  many  examples  of  epi- 
thelioma being  operated  on  successfully  and  not  followed  by  relapse 
that  I  never  despair  of  attempting  complete  ablation.  Therefore  it  is 
well  worth  while  to  discover  the  best  methods  of  treatment  and 
operation. 

With  regard  to  the  seat,  cancer  of  the  cervix  is  the  only  one  which 
admits  of  curative  treatment.  In  the  cervix  itself  scirrhus  or  ence- 
phaloid, apart  from  being  manifestations  of  a  diathetic  affection  for 
which  we  know  no  remedy,  are  usually  developed  too  deeply  to  allow 
of  our  exceeding  the  limits  of  the  disease ;  and  operation  in  their  case 
is  only  practicable  when  they  present  themselves  under  certain  favor- 
able conditions.  These  conditions  are  the  following  : — The  cancer 
must  occupy  the  vaginal  portion  of  the  cervix ;  it  must  not  extend  to 
the-  vaginal  insertions  still  less  to  the  vagina  itself,  as  often  occurs  j 
the  cervix  above  the  organic  alteration  must  be  indolent,  only  slightly 
tumefied,  supple,  soft,  without  suspicious  indurations,  in  short,  in  a 
normal  condition. 

I.  Curative  treatment. — We  cannot  count  on  any  specific  but  must 
limit  ourselves  to  restoring  the  constitution  by  tonics  and  alteratives, 
the  value  of  which  has  been  proved  by  experience.  We  should  pre- 
scribe a  strengthening  diet,  milk,  residence  in  the  country,  or  at  a 
watering  place  appropriate  to  the  temperament,  hydropathy  and, 
according  to  the  requirements  of  the  case,  the  use  of  iron,  preparations 
of  gold,  arsenic  and  even  of  hemlock.  Ablation,  however,  is  the 
only  curative  treatment  effected  either  by  the  use  of  caustics  or  by 
operation. 

A.  The  destruction  of  cervical  cancer  by  caustics  is  the  most  seduc- 
tive means  for  an  inexperienced  practitioner.  Unfortunately  it  is  not 
successful  whilst  its  innocuity  is  only  apparent.  Caustics  are  useless 
because  they  cannot  reach  even  by  repeated  applications  the  whole 
extent  of  the  evil :  caustics  or  solvents  of  cancerous  elements  such  as 
gastric  juice  (Sennebier  of  Geneva),  acetic  acid  (Broadbent),  tincture 
of  sesquichloride  of  iron  (Kiwisch),  the  solution  of  nitrate  of  silver 
(Thiersch,  Hermann,  Laurent,  Kuhn,  Nussbaum  ^),  perchloride  of  iron 
(Gallard),^  only  destroy  a  small  portion  of  the  tumour  and  may  set  up 
fatal  inflammation. 

Caustics  are  hurtful  not  only  because  they  may  by  spreading  attack 
other  parts  than  those  to  which  they  are  applied,  but  because  their 
action,  though  incomplete  as  a  destructive,  is  energetic  as  an  excitant 
and  frequently  determines  a  proliferation  the  effects  of  which  have 
always  seemed  to  me  to  increase  the  evil  it  was  intended  to  lessen.  I 
neither  except  acids,  nor  acid  nitrate  of  mercury,  nor  Canquoin's 
caustic,  nor  the  actual  cautery.     I  would  only  sanction  the  use  of  the 

Monatscli.  fur  Geburtsh.,  1867,  Bd.  xxx,  S.  230. — Bayerisches  aerztliches 
IntelUgenzbl,  Heft  17,  23  April,  1867.— Gaz.  liehdom.,  1867,  p.  333. 
^  Gaz.  des  hopitaux,  July  6,  1867. 


704  UTEEINE    DISEASES    IN    DETAIL 

latter  on  a  very  superficial  surface  of  epithelioma  or  on  a  very  limited 
corroding  cancer  which  could  be  destroyed  entirely  by  one  application. 
This  is  sometimes  effected  by  applying  a  small  circle  of  Canquoin's 
caustic  to  the  cervix  and  a  cylinder  of  the  same  plaster  in  its  cavity ; 
I  have  for  a  long  time  adopted  this  method,  which  is  somewhat  similar 
to  that  recommended  by  Maissoneuve  under  the  name  of  cauterisation 
enfieclie.  We  may  also  make  an  interstitial  injection  of  a  solution  of 
chloride  of  zinc  (Guichard,  Annales  de  Gynecologie,  1877).  In  what- 
ever way  the  Canquoin  is  applied  we  should  prevent  the  possibility  of 
its  displacement  and  the  consequent  destruction  of  healthy  parts  by 
retaining  it  in  position  by  methodic  plugging  of  the  vagina  with  oiled 
cotton  wool  and  by  keeping  the  patient  in  bed.  It  is  left  for  a  longer 
or  shorter  period  according  to  the  depth  of  destruction  required;  and 
it  may  be  re-applied  for  several  days,  the  plugging  being  continued  to 
prevent  cauterisation  of  the  vaginal  mucous  membrane  by  the  detach- 
ment of  fragments  from  the  scar  of  the  cervix.  It  will  be  seen  that 
this  application  requires  great  care  and  cannot  be  made  without  danger 
by  an  inexperienced  practitioner. 

B.  Amputation  of  the  cervix  is  the  only  means  of  completely  removing 
the  disease.  I  have  already  laid  down  the  indications  and  contra- 
indications for  and  against  amputation^  of  the  cervix.  They  may  be 
resumed  as  follows  :  amputation  is  contra-indicated  when  the  cervix  is 
not  the  only  point  of  localisation  of  the  cancerous  affection,  even  when 
this  diathetic  affection  has  not  reached  the  stage  of  cachexia ;  when  the 
cancer,  however  local  it  appears,  is  deeply  seated  not  only  in  the  body 
but  also  on  the  supra- vaginal  portion  of  the  cervix  ;  when,  having 
begun  at  the  free  extremity  of  the  cervix,  it  is  propagated  even  beyond 
the  level  of  the  vaginal  insertions  of  this  organ  ;  when,  the  supra- 
vaginal portion  of  the  cervix  remaining  healthy,  the  vagina  is  invaded 
by  the  cancer,  even  to  a  slight  extent,  except  when  under  the  form  of 
very  superficial  excrescences  without  deep  roots,  easily  removed  by 
scissors  without  prejudice  to  a  subsequent  cauterisation,  the  conse- 
quences of  which  cannot  compromise  the  integrity  of  the  bladder  or 
rectum.  Amputation  is  indicated  when  the  cancer  is  situated  on  the 
free  extremity  of  the  cervix,  whatever  its  size  may  be ;  when  no  other 
localisations  exist  either  in  the  upper  portion  of  this  organ,  or  in  the 
body  of  the  uterus,  or  in  any  other  viscusj  when  the  supra -vaginal 
portion  corresponding  to  the  vaginal  insertions,  and  especially  that 
part  comprised  between  these  insertions  and  the  tumour,  have  pre- 
served their  normal  size,  suppleness  and  insensibility ;  lastly,  when  the 
organic  alteration  is  not  propagated  in  any  direction  on  the  vaginal 
mucous  membrane  :  under  these  circumstances  amputation  of  the  cervix 

'  Amputation  of  the  cervix  was  first  performed  in  1802  by  Osiander,  who 
repeated  it  23  times  {Heilung  des  Mutterhrebses,  dx.,  durch  Schnitt.,  in  Eeich- 
anzeiger,  1803). — Langenbeck  (De  totius  uteri  extirpatione.  Goettingen,  1842, 
p.  26^. — Since  then  it  has  been  often  performed  by  Dupujtren  {Journ.  gen.  de 
vied.,  cix,  214),  and  by  Lisfranc  {Gaz.  med.  de  Paris,  1S24,  p.  387.  Clinique 
de  la  Pitie,  iii,  645.  JParis,  1843),  Pauly  {Maladies  de  I'tdenis.  Paris,  1836), 
Simpson  {Edinb.  Med.  and  Surg.  Journ.,  1841 ;  Dublin  Journal,  1846 ; 
Medical  Times,  1859),  &c. 


CANCER  705 

ou£jlit  to  be  performed,  this  operation  being  the  only  means  of  saving 
Hfe^ 

I  say  under  these  circumstances,  and  I  only  speak  of  amputating  the 
intra- vaginal  portion  of  the  cervix ;  i.e.  I  reject  as  useless  or  dangerous 
amputation  of  the  supra-vaginal  portion  of  the  cervix  and^  still  more 
so,  extirpation  of  the  whole  uterus  in  cases  of  cancer.  Unfortunately 
these  operations  were  common  enough  at  one  period  to  afford  materials 
upon  which  to  base  a  serious  opinion  as  to  their  advisability.^ 

1.  When  the  cervix  is  amputated  by  linear  ecrasement,  chloroform 
should  first  be  administered.  The  patient  should  be  in  the  lithotomy 
position.  An  assistant  on  each  side  by  passing  a  hand  or  arm  under 
the  knee  and  seizing  the  instep  with  the  other  hand  can  hold  the  leg 
flexed,  separate  the  thighs,  raise  or  depress  the  buttocks  according  as 
the  operator  may  require.  If  the  uterus  can  be  displaced  easily  1  do 
not  see  any  contraindication  to  drawing  it  down  gently  to  a  level  with 
the  vulva,  which  greatly  facilitates  the  operation ;  if  not,  a  curved 
ecraseur  should  be  used,  or  better  still  a  simple  iron  wire  in  place  of  a 
chain  which  is  passed  round  the  pedicle  of  the  tumour.  To  do  this 
the  tumour  must  be  seized  as  if  it  were  to  be  drawn  towards  the 
vulva.  By  fixing  it  in  this  manner  we  facilitate  the  application  of  the 
chain.  Museux's  tenaculum  hook  forceps  may  be  used  for  the 
purpose  or  ani/  other  form  of  polypus  forceps  (see  p.  684)  :  the 
tumour  is  seized  at  various  points,  a  little  behind  if  possible  in 
order  to  run  less  chance  of  lacerating  it  and  to  be  more  sure  of  apply- 
ing the  ecraseur  beyond  the  limits  of  the  disease.  Robertas  tenaculum 
hook  forceps  although  rather  strong  are  sometimes  better  when  we 
wish  to  ensure  their  insertion  into  the  deep  portion  of  the  cancer 
towards  the  upper  border  of  the  tumour  :  their  introduction  is,  besides, 
very  easy ;  they  are  applied  one  after  the  other  right  and  left  of  the 
cervix  and  are  then  articulated  like  forceps ;  they  are  separated  more 
easily  than  Museux^s  forceps.  Chassaignac's  tenaculum  hook  with 
diverging  branches  may  also  be  used  ;  it  is  introduced  closed  into  the 
cervical  cavity;  the  hooks  are  then  made  to  diverge  and  by  exercising 
traction  upon  them  the  cervix  is  hooked  from  within  and  can  be  drawn 
down  more  easily  than  by  the  claws  of  forceps.  Here,  however,  a 
difficulty  presents  itself.  Whilst  on  the  lower  side  we  may  be  afraid 
of  not  reaching  the  limits  of  the  cancer,  on  the  upper  side,  on  the 
contrary,  there  is  reason  to  fear  that  a  portion  of  the  vagina  may  be 
included  in  the  chain  with  the  cervix,  especially  if,  owing  to  the 
obliquity  of  the  cervix,  the  greater  development  of  the  tumour  on  one 
of  the  lips  than  on  the  other,  the  traction  exercised  on  the  cervix  and 
the  movements  imparted  to  it  in  order  to  facilitate  the  passage  of  the 

^  As  to  the  advantages  and  di-awbacks  of  this  operation  consult  Simpson, 
op.  cit.,  p.  169 ;  West,  op.  cit.,  p.  415  ;  Velpeau,  Medecine  operatoire,  iv,  413. 
Paris,  1839. 

2  West,  Diseases  of  Women,  p.  412.  — SeiTe,  Pathologie  et  therajjeutique  des 
onaladies  pour  lesquelles  on  a  prescrit  diverses  amputations  de  la  viatrice; 
examen  critique  de  ces  may  ens,  et  description  des  diverses  methodes  de  ees 
amputations.  Montpellier,  1834. — Langenbeck,  op.  cit. — Eobert,  Z^es  affections 
granuleuses  ulcereuses  et  carcinomateuses  du  col  de  I'uterus.  Paris,  1848. 

45 


706 


UTERINE    DISEASES    IN    DETAIL 


chain,  we  fail  to  give  it  a  direction  perpendicular  to  the  plane  of 
section  passing  through  all  the  radii  of  the  circle  described  by  the 
metallic  ring  of  the  ecraseur.  This  danger  is  not  imaginary ;  a  real 
difticulty  is  experienced  in  preventing  the  chain,  tvhen  it  has  been 
adjusted   on   one   side   to   the  desired  portion   of  the   cervix,   from 


Fig.  386. — Chassaignac's  diverg-      Fig.  387. — Amputation  of  the  cervix  by 
ing  tenaculum  hooks.  linear  ecrasement. 

embracing  on  the  other  side  a  part  of  the  vagina  and  with  it  a  portion 
of  the  bladder  or  rectum  or  at  least  of  the  utero-vagino-rectal  ^  peri- 
toneum. A  ligature  of  thread  should  be  first  employed  as  Chas- 
saignac  recommends,  as  a  preliminary  in  every  operation  for  ecrase- 

1  Scanzoni's  Beitrclge,  iii,  80.  Wurzhurg,  1858. — Monatssch.  filr  Geburtsk., 
March,  1858. 


CANCER  707 

ment ;  but  it  is  not  much  easier  to  adjust  this  hgature  in  the  exact 
situation  than  to  fix  the  chain. 

With  the  object  of  preventing  this  accident  I  have  invented  an 
instrument  which  is  nothing  but  a  pair  of  long  disarticulating  forceps, 
the  branches  of  which  can  be  introduced  successively  and  articulated 
afterwards,  their  concave  blades,  which  are  bent  at  right  angles,  forming 
when  united  a  kind  of  ring  which  embraces  the  cervix  above  the  diseased 
part.  It  is  easy  then  to  grasp  the  organ  and  to  make  sure  with  the  index 
finger  that  it  alone  is  seized  by  the  instrument,  or,  if  otherwise,  to  push 
back  the  portion  of  the  vagina  which  has  been  included,  to  bring  the 
axis  of  the  cervix  once  more  into  a  position  perpendicular  to  the  circular 
surface  of  the  projected  section,  to  keep  it  there  by  tightening  the 
blades  of  the  forceps,  and  to  adjust  with  precision  around  the  cervix, 
immediately  below  the  forceps,  the  metallic  ligature  or  the  chain  of  the 
ecraseur,  which  may  then  be  pushed  back  towards  the  blades  as  it  is 
tightened,  so  as  to  avoid  the  double  danger  of  dividing  the  cervix  too 
high  or  too  low.^  As  soon  as  we  are  sure  of  the  point  of  application 
the  operation  proceeds  by  itself,  its  only  drawback  being  its  slowness; 
every  two  or  three  minutes  the  chain  is  tightened  by  one  notch,  the 
patient  being  kept  under  chloroform  till  the  section  is  finished. 
Sometimes  I  have  performed  the  same  operation  with  a  metallic  wire 
and  a  good  serre-nceiul,  effecting  constriction  slowly  by  turning  the 
screw  every  quarter  of  an  hour.  I  have  done  it  in  a  day  without 
having  recourse  to  chloroform,  except  at  the  commencement  of  the 
operation  which  is  always  painful,  and  without  causing  the  least  hse- 
morrhage.  The  operation  may  be  extended  over  a  still  longer  period 
without  harm  if  hot  detersive  injections  are  made  from  time  to  time, 
as  is  done  in  cases  of  simple  application  of  the  ulcerative  ligature. 
Immediately  after  the  fall  of  the  tumour  a  hemostatic  injection  is 
made,  and  care  should  be  taken  to  ascertain  by  digital  touch  that  no 
suspicious  tissue  is  left  on  the  cervix,  and  a  wooden  speculum  should  be 
introduced  into  the  vagina  in  order  to  examine  the  wound.  If  any  can- 
cerous indurations  are  left,  they  may  be  excised  with  a  long  narrow 
bistoury,  perchloride  of  iron  being  afterwards  applied  to  the  womb 
to  stop  hsemorrhage,  or  better  still  a  mushroom-shaped  cautery  or  a 
jet  of  gas  which  has  the  advantage  of  destroying  all  traces  of  the 
cancer,  acting  as  a  hemostatic  as  well  as  modifying  the  uterine  tissues 
and  encouraging  resolution  of  the  chronic  phlegmasia  which  has  been 
kept  up  to  some  depth  by  the  long  duration  of  the  development  of 
the  cancerous  tumour. 

2.  When  excision  is  performed  we  may  dispense  with  chloroform  on 
account  of  the  rapidity  of  the  operation  ;  the  patient  should  be  in  the 
same  position  as  for  ecrasement;  the  cervix  is  seized  by  tenaculum 
forceps  and  is  either  drawn  down  to  the  vulva  or  operated  on  in  situ? 

'  Simon  of  Darmstadt,  Monatsch.  fur  Geburtsh.,  xiii,  418  and  434. 

2  I  do  not  enumerate  the  various  metliods  of  excision  of  the  cervix  performed 
by  Osiander,  Recamier,  Dupuytren,  Lisfranc  and  Simpson,  or  tliose  invented  by 
Hatin  {AmiJutation  du  col  cle  la  matrice.  Paris,  1827),  Colombat  {Hysterolo- 
mie.  Paris,  1828),  Canella  {Cenni  suW  esfArpazione  clella  bocca  del  collo  dell' 
utero.  Milan,  1821)  and  Aronsohn  {Zeitschriftfilr  die  gesammte  Medicin,\,  -I'Sd^. 


708  UTERINE    DISEASES    IN    DETAIL 

The  first  method  is  uudoubtedlj  the  best^  for  by  operating  on  the 
uncovered  tumour  if  there  are  any  adhesions  with  the  vagina  we  do 
not  run  the  risk  of  including  them  in  the  section.  This  danger  is  to 
be  feared  when  the  cervix  is  left  in  place,  but  in  such  cases  we  may 
apply  the  forceps  with  bent  blades  behind  the  line  of  projected  section, 
immediately  in  front  of  the  vaginal  insertions,  or  we  may  attack  the 
cervix  from  various  directions,  inclining  it  alternately  in  one  direction 
or  another,  always  to  the  side  opposite  to  that  by  which  we  wish  to 
attack  it  and  protecting  the  corresponding  portion  of  the  vaginal  wall 
with  dilators.  When  section  is  begun  in  this  way  all  round,  it  is  easy 
by  taking  this  first  groove  as  a  guide  to  finish  ablation  of  the  tumour. 
If  it  is  necessary  to  dissect  the  vaginal  insertion  at  some  point  or  to 
pare  the  cervix  into  the  shape  of  a  funnel  or  hollow  cone  (which  is  a 
good  precaution  to  take  when  we  suspect  that  the  cancer  is  propagated 
towards  the  cervical  cavity)  the  bistoury  is  necessary ;  it  is  better  to 
choose  one  with  a  long  handle  as  being  easier  to  manage,  and  with  a 
short  blade  which  is  easily  inclined  in  various  directions  and  which  can 
be  carried  all  round  the  pedicle  represented  by  the  cervix.  We  may  even 
require  a  bistoury  with  a  very  long  handle  and  a  very  short  blade, 
bent  or  concave  like  a  small  pruning  hook  when  excision  has  to  be 
performed  at  the  further  extremity  of  the  vagina.  If  we  are  sure  of 
removing  all  by  one  stroke,  and  without  injuring  any  surrounding 
organ,  we  may  use  very  strong  scissors  slightly  curved,  when  the 
cervix  is  drawn  down  to  the  vulva.  The  same  instrument  with  blunt 
points,  guided  by  the  index  finger,  is  very  useful  in  commencing  sec- 
tion of  the  cervix  at  the  further  extremity  of  the  vagina.  It  does  not, 
like  the  bistoury,  present  the  risk  of  cutting  the  cervix  at  other  points 
than  that  to  which  it  is  applied.  Whether  the  choice  falls  on  a  knife 
or  scissors  section  of  the  cervix  should  usually  be  begun  at  the  poste- 
rior lip  and  terminated  at  the  anterior  one,  so  as  to  begin  with  the 
most  difficult  section  and  to  avoid  the  blood  issuing  from  the  parts 
already  divided. 

After  complete  separation  of  the  cervix  perchloride  of  iron  or  the 
actual  cautery  should  be  appUed,  the  same  precautions  being  used  as 
after  ablation  of  the  cervix  by  the  linear  ecraseur. 

This  operation  is  not  so  free  from  risk  as  might  be  supposed.  Cruveil- 
hier  mentions  the  case  of  a  young  lady  who  died  a  few  hours  after- 
wards, therefore  it  should  only  be  performed  when  really  indicated  and 
with  all  necessary  precautions.  Except  in  the  rare  cases  in  which  it 
has  been  followed  by  death  the  symptoms  of  reaction  which  it  pro- 
duces are  usually  moderate.  In  some  patients  there  is  perfect  toler- 
ance; but  in  the  majority  symptoms  of  metritis  are  manifested.  The 
loss  of  blood  is  not  usually  great ;  it  can  be  arrested  when  necessary 
by  perchloride  of  iron  and  plugging.  Lumbar  pain,  however,  due  to 
the  dragging  exercised  on  the  uterus  during  the  operation,  lasts  for 
some  hours  and  often  for  days.  Pain  is  developed  in  the  vagina  and 
hypogastrium  and  is  aggravated  by  pressure,  but  is  rarely  of  an  alarm- 
ing character,  simple  emollient  cataplasms,  sedative  fomentations, 
embrocations  with   camphorated    oil   sufficing   to   alleviate  it.     But 


CANCEE  709 

however  slight  the  symptoms  of  metritis  or  peritonitis  appear^  no  time 
should  be  lost  in  treating  them  by  the  application  of  a  number  of 
leeches,  by  frictions  with  mercurial  and  belladonna  ointment  made 
every  two  hours,  and  afterwards  by  mild  laxatives,  emollient  cataplasms, 
and  all  the  antiphlogistic  and  resolvent  means  applied  to  the  treatment 
of  acute  metritis.  Patients  should  be  confined  to  bed  till  these  sym- 
ptoms have  disappeared.  We  should  then  await  the  fall  of  the  scar 
and  pay  attention  to  the  cicatrisation  of  the  wound.  Even  when 
cicatrisation  is  neither  slow  nor  irregular,  if  unhealthy  looking  granu- 
lations appear  on  the  surface  of  the  wound  we  must  not  fear  to  destroy 
them  quickly  and  completely,  by  the  actual  cautery^  Vienna  or  arsenical 
paste,  which  may  be  retained  against  the  cervix  with  a  pledget  of 
lint  or  cotton  wool.  I  have  found  the  latter  method  of  great  use  in 
such  cases,  as  it  induces  speedy  and  healthy  cicatrisation.  I  consider 
it  as  a  good  supplement  to  the  other  caustics  which  effect  mortification 
or  destruction  of  a  certain  depth  of  tissue,  but  the  scar  of  which  does 
not  always  present  the  subjacent  formation  of  a  true  cicatrix  after  its 
fall.  Arsenical  paste  applied  at  this  time  has  usually  seemed  to  me  to 
possess  the  property  of  producing  real  cicatrisation  of  the  wound  in  place 
of  fresh  destruction.  In  order  to  profit  by  the  advantages  offered  by  the 
elastic  ligature  and  Paquelin's  thermo-cautery,  I  have  modified  the 
operation  in  the  following  way.  Let  us  take  the  case  of  a  voluminous 
tumour  of  vegetating  epithelioma.  And  here  I  may  remark  that  the 
analogy  of  aspect  to  which  the  English  have  drawn  attention  between 
the  vegetating  epithelioma  of  the  cervix  and  the  cauliflower  (cauli- 
flower excrescence)  is  more  real  than  one  would  suppose  on  a  super- 
ficial examination.  I  have  always  remarked  in  these  cancerous  or 
cancroidal  cauliflower  excrescences  two  distinct  portions :  1,  an  exu- 
berant friable  part,  formed  of  voluminous  epithelial  elements  appended 
to  vascular  arborisations  which  support  thein  like  grapes  in  a  cluster; 
these  parts  form  lobules  and  lobes  the  removal  of  which  is  often  easy, 
not  being  even  accompanied  by  serious  haemorrhage :  therefore  they 
can  always  be  removed  more  or  less  readily.  Sometimes  it  is  necessary 
to  have  recourse  to  a  ligature  and  then  they  fall  very  easily.  When  I 
use  the  ligature  it  is  to  remove  more  of  the  tumour,  or  else  because 
the  tissue  of  it  is  different;  2,  a  dense  resistant  portion,  also  sub- 
divided into  tapering  parts  which  correspond  with  the  principal  and 
even  secondary  lobes  which  they  sustain  and  of  which  they  form  the 
trunk  and  principal  branches.  This  trunk,  formed  of  much  smaller 
and  denser  epithehal  elements  than  the  preceding,  of  conical,  oval, 
tapering  cells  and  of  longer  or  shorter  fibrillse  and  fibres,  is  hard  and 
resistant  although  sometimes  very  vascular  and  penetrating  more  or 
less  into  the  tissue  from  which  it  has  arisen  (the  border  of  the  lip,  its 
external  or  internal  surface)  and  in  which  it  is  inserted  by  a  more  or 
less  broad  base.  It  is  this  portion  (the  root  of  the  vegetating  pro- 
duct) which  must  be  destroyed  as  deeply  as  possible,  at  first  with 
instruments  or  the  cautery,  afterwards  with  caustics  (arsenical  paste) 
so  as  to  avoid  fresh  vegetation  of  the  epithelioma.  In  order  to  use  all 
the  precautions  which  prudence  suggests,  supposing  the  cauliflower 


■10 


UTERINE    DISEASES    IN    DETAIL 


tumour  is  very  large,  I  try  to  constrict  the  pedicle  behind  the  vegeta- 
tion by  an  elastic  ligature.  This  produces  ulceration  of  the  trunk,  or 
at  least  the  vegetations  fall  rapidly,  leaving  bare  the  trunk  from  which 
they  rose,  which  is  of  denser  tissue. 

It  is  this  portion  that  must  be  completely  removed  if  we  would 
avoid  a  recurrence  of  the  disease.  In  order  to  succeed  with  as  little 
pain  and  hsemorrhage  as  possible  we  should  amputate  the  whole  cervix 
(if  it  is  the  whole  cervix  which  forms  the  base  of  the  tumour)  by 
means  of  the  galvano-caustic  wire,  or  else  excise  the  root  of  the  disease 


Fig.  388. — Excision  of  a  cancerous  tumour  of  the  anterior  lip  of  the  cervix 
by  the  actual  cautery,  s,  a  boxwood  speculum,  depressing  the  posterior 
vaginal  wall ;  p,  tenaculum  forceps  seizing  the  tumour  ;  c,  cautery  excising 
the  tumour,  hollowing  out  the  tissue  of  the  anterior  lip  in  order  to  reach 
the  extremity  of  its  root. 

(usually  inserted  in  one  of  the  lips)  with  curved  sharp  cauteries  or 
with  the  curved  knife  of  the  thermo-cautery  (Collin  has  made  a 
thermo-cautery  knife  for  me  which  has  a  curve  fitting  it  for  this  little 
operation).  The  vagina  is  protected  by  means  of  univalve  boxwood 
specula.  The  tumour  is  then  seized  by  tenaculum  forceps  and 
inclined  in  various  directions,  so  that  its  root  may  be  separated  from 
the  healthy  tissue  as  deeply  as  appears  necessary  by  means  of  a  cautery 
in  the  form  of  a  straight  or  curved  knife.  The  third  part  of  the 
operation  consists  in  directing  the  cicatrisation  of  the  ulcer  which 
follows  excision  of  the  root  of  the  cauliflower,  and  to  attain  this  end 


CANCER  711 

no  preparations  seem  to  me  so  good  as  those  of  arsenic.  Fowler's  solu- 
tion or  Eriar  Gome's  powder :  these  should  be  employed  with  great 
care,  for  if  too  much  is  used  at  once  poisoning  may  be  produced.^ 

Is  surgical  intervention  impossible  for  epithelioma  of  the  uterine 
cavities?  Whilst  admitting  that  it  is  far  less  effectual  than  in  the  pre- 
ceding case,  I  do  not  think  it  should  be  neglected.  When  epithelioma  is 
developed  on  the  mucous  membrane  of  the  fundus,  surgical  intervention 
ought  to  be  confined  to  dilatation  of  the  cervix  with  sponge  tents, 
scraping  with  the  curette  and  the  application  of  solid  or  liquid  caustic 
to  the  abraded  surfaces.  When  epithelioma  is  developed  on  the 
mucous  membrane  of  the  cavity  of  the  cervix,  especially  when  it 
assumes  the  form  of  cauliflower  excrescence,  we  may  hope  to  destroy  it 
even  if  forced  to  incise  one  of  the  lips  of  the  uterus,  especially  the  one 
that  is  healthy  and  distended  by  the  development  of  the  diseased 
segment. 

II.  Palliative  treatment. — I.  General  palliative  treatment  consists 
in  giving  tone  to  the  organism  and  in  subduing  nervous  symptoms, 
especially  pain. — The  physician  ought  to  initiate  an  intelligent,  ener- 
getic and  continuous  struggle  between  the  lesion  which  attacks  and  the 
organism  which  defends  itself.  The  best  means  for  restoring  the  con- 
stitution and  so  enabling  it  to  resist  the  progress  of  cancer  as  much  as 
possible  are :  residence  in  the  country,  generous  diet  with  plenty  of 
milk  and  the  use  of  the  medicaments  which  I  have  indicated  as  suit- 
able to  the  treatment  of  tne  accompanying  dyspepsia  :  bitters,  bark 
and  iron. — The  nervous  symptoms  and  paroxysms  of  pain  should  be 
treated  by  antispasmodics  or  narcotics :  preparations  of  hemlock,  hen- 
bane, belladonna,  Indian  hemp,  opium  and  the  difi'erent  salts  of  morphia 
alone  or  combined  with  ether  and  administered  by  the  mouth, 
or  subcutaneously ;  sedative  embrocations  with  the  oil  of  henbane 
or  belladonna  either  alone  or  mixed  with  chloroform ;  laudanum 
in  small  rectal  injections  given  with  a  long  cannula ;  linseed  poultices 
made  with  the  infusion  of  poppy-heads ;  sitz-baths  and  even  general 
baths  containing  decoctions  of  poppy-heads,  henbane  or  hemlock 
leaves  ;  suppositories  containing  gr.  \  of  the  extract  of  belladonna  and 
an  equal  portion  of  the  extract  of  opium,  which  the  patient  may  intro- 
duce into  the  rectum  every  24  hours  or  oftener.  Vaginal  pessaries  of 
iodoform  (15  grains  made  with  cacao  butter"),  &c.  The  poultices, 
sitz-baths  or  general  baths  ought  to  be  hot  or  tepid. 

2.  Local  palliative  treatment  consists  in  the  use  of  resolvents, 
hemostatics  and  disinfectants.  The  resolvents  are :  mercurial  and 
belladonna  ointment  or  an  ointment  composed  of  equal  parts  of  the 
iodide  of  lead  and  potassium  applied  by  friction  to  the  hypogastrium 
and  groins.  Resolvents  may  also  be  applied  to  the  cervix  in  the  form 
of  plasters  of  hemlock  and  tampons  saturated  with  strong  solu- 
tion of  chlorate  of  potassium  (said  by  Bergeron  to  be  effectual  in  epi- 

^  Traitement  palliatif  du  cancer  de  I'uterus.  Communication  made  to  the 
Association  for  the  Promotion  of  Science  in  France,  27  August,  1877.  Gaz. 
hebdomadaire  de  inedecine  et  de  chirurcjie,  Sept.,  1877. 

2  Greenhalgh,  Eastlake  {Obstet.  Soc.  of  London,  1866  ;  British  Med.  Journ., 
1866)  ;   Demarquay  {Bulletin  de  Thcrapeutique,  1867) ;  G.  Woiker  (id.,  ibid.). 


712  DTEEINE    DISEASES    IN    DETAIL 

thelioma  of  the  lips).  These  local  applications  prepare  the  tissues  for 
the  direct  and  energetic  action  of  other  medicaments;  the  latter  espe- 
cially seems  to  soften  the  pathological  tissue  and  facilitate  its  subse- 
quent destruction, — Hemostatics  are  useful  in  preventing  patients 
from  being  weakened  by  hemorrhage.  The  tincture  of  cinnamon, 
ergot  and  the  various  hemostatic  vraters  may  be  given  internally,  or 
12  gr.  of  tannic  or  gallic  acid  may  be  given  every  4  hours,  or  rhatany, 
catechuj  or  5  to  20  drops  of  perchloride  of  iron  twice  a  day  in  a  little 
water,  followed  by  a  cup  of  milk. — As  for  the  local  application  of 
hemostatics,  injections  should  be  made  with  vinegar  and  cold  water 
or  with  perchloride  of  iron  (5iss  to  the  quart  of  water)  or  with 
infusion  of  matico  or  oak-bark;  or  perchloride  of  iron  may  be  applied 
undiluted  after  having  washed  the  ulcer  well  with  injections  of  cold 
water,  taking  care  to  remove  all  that  remains  of  the  perchloride  with  a 
little  cotton  wool.^  Indirect  means  of  hemostasis  should  also  be  em- 
ployed, such  as  semi-flexion  in  a  horizontal  posture,  very  hot  injections 
morning  and  evening,  absolute  rest  during  menstruation,  moderate 
exercise  in  the  intercalary  period,  the  interruption  of  marital  inter- 
course, milk  diet,  &c. 

The  daily  use  of  disinfectants  is  indispensable.  In  addition  to 
baths  vaginal  injections  should  be  prescribed  morning  and  evening, 
in  order  to  expel  the  ichor  of  the  cancerous  surfaces  as  well  as 
the  decomposed  debris. — Sedative  injections  have  very  little  effect 
owing  to  the  very  slight  absorbing  power  of  the  vagina ;  this  defect, 
however,  is  compensated  for  by  the  facility  of  applying  narcotics 
to  the  rectum,  and  the  same  remark  applies  to  medicated  pessa- 
ries. The  only  injections  that  are  of  any  use  are  those  that  are 
disinfectant  and  detersive;  they  should  be  made  with  very  hot  water, 
to  which  is  added  a  spoonful  of  the  solution  of  permanganate  of 
iron  or  potassium  (1  per  cent.)  or  carbolic  acid.  Some  patients  find 
aromatic  injections  useful.  After  the  injection  the  diseased  surface 
may  be  touched  with  one  of  the  following  medicaments  :  creasote^ 
chromic,  boracic  or  carbolic  acid,  perchloride  of  iron,  solution  of 
tannin,  concentrated  solution  of  nitrate  of  silver  (10  per  cent.)  or 
Fowler's  solution.  They  have  the  effect  of  preventing  the  exudation 
of  blood,  of  coagulating  lymph  and  albumen  and  contracting  the  tissues ; 
in  fact  of  tanning  the  surface  of  the  tumour  to  a  considerable  extent, 
as  they  can  be  applied  with  a  brush  to  the  interstices  and  infractuosities 
of  the  cancerous  excrescence  ;  the  result  is  a  superficial  desiccation  of 
the  tumour  or  ulcer,  and  sometimes  the  course  of  the  organic  altera- 
tion is  arrested.  I  have  found  these  local  applications  of  great  use 
associated  with  other  local  and  general  means ;  they  make  the  cancer 
tolerable  till  the  period  of  cachexia  arrives ;  in  fact  this  treatment  may 
prolong  life  when  the  cancer  has  not  a  very  progressive  tendency  and 
when  the  corroding  ulcer  is  not  very  extensive. 

I  will  end  this  chapter  by  a  few  words  on  the  course  to  be  pursued 
during  gestation  or  labour.     If  we  have  reason  to  hope  that  the  life  of 

^  Sims's  speculum  should  be  used,  the  patient  being  in  the  elbow  and  knee 
position,  which  is  the  most  convenient  for  dressings  in  cancerous  diseases. 


CANCER  713 

the  patient  may  be  prolonged^  whilst  the  disease  is  such  as  to  render 
delivery  dangerous,  we  may  produce  abortion  or  premature  delivery  ; 
if  not  we  should  wait.  If  labour  has  commenced  we  should  wait  till 
expulsive  eflbrts  have  become  ineffectual ;  if  after  a  certain  time  no 
part  of  the  orifice  nor  inferior  segment  is  sufficiently  dilated  to  allow 
of  the  passage  of  the  child,  deep  incisions  into  the  cervix  and  cervical 
canal  are  indicated,  and  in  desperate  cases  Csesarean  section  may  be 
necessitated  (West,  op,  cit.,  p.  410). 


CHAPTEE   V 

DISEASES  OF  THE  UTEEIJfE  APPEXDAGES — PELVIC  H^MOEEHAG-ES  AND  PEEI- 
FTEEEN-E  HEMATOCELE — CYST  OF  THE  OYAET  XSD  GEXITO-PELTIC  TTJIIOUE 
— STEEILITT 

The  number  of  diseases  which  remain  to  be  described  is  reduced  to 
three :  1^  pelvic  lisemorrhages  and  hematocele  which  is  often  the 
consequence  of  them ;  2,  tumours  of  the  ovaries  and  tubes,  especi- 
ally ovarian  cysts,  in  the  description  of  which  I  have  included  not 
only  ovariotomy  but  hysterectomy ;  3,  sterility,  the  incurable  causes 
of  which  must  not  be  confounded  with  those  residing  in  the  vagina 
or  uterus,  which  are  more  accessible  to  investigation  and  less  difficult 
to  treat. 


Pelvic  Hjemoerhages  and  Peri-uterine  Hematocele 
1.  Pelvic  Kamorrliages 

Heemorrhages  which  occur  in  the  cavity  of  the  pelvis'  may  arise 
from  different  sources ;  for  the  cavity  contains,  besides  very  vascular 
organs,  important  arterial  and  venous  vessels. 

We  shall  confine  our  study  to  those  which^  having  their  starting- 
point  in  the  uterine  system  in  the  state  of  vacuity,  are  capable  of 
forming  a  tumour  and  of  being  produced  under  the  three  following 
conditions :  absence  of  pregnancy,  starting-point  in  the  uterine 
system,  sufficient  quantity.  With  regard  to  the  theories  which  have 
been  expressed  as  to  the  origin  of  the  extravasated  blood,  I  shall  make 
the  following  remarks  : 

1.  The  theory  of  Nelaton  and  Laugier  (menstrual  haemorrhage  of 
the  Graafian  follicle  and  morbid  vesicular  hsemorrhage^),  has  no  founda- 
tion from  a  physiological  point  of  view,  since  a  Graafian  vesicle 
may  be  ruptured  without  any  discharge  of  blood,  and  morbid  vesi- 
cular haemorrhage  gives  rise  to  passive  effusions  which  are  easily 
absorbed  on  the  spot.^ 

^  The  exaggerated  natural  haemorrliage  of  the  Graafian  vesicle  may  occur  at 
the  moment  of  dehiscence  (Xelaton),  or  at  repeated  dehiscences  (Laugier),  or 
from  the  passive  exudation  which  precedes  or  accompanies  the  formation  in  the 
vesicle  of  the  coijms  luteum.  Morbid  or  pathological  hjemorrhage  of  the 
ovary  is  produced  either  in  the  vesicle  or  in  the  parenchyma  (in  the  latter  case 
it  is  called  apoplectic,  from  its  analogy  with  the  haemorrhage  which  causes 
apoplexy). 

^  Eobert,  Gaz.  med.  de  Paris,  1857,  p.  1. — Puech,  De  I'hematocele  peri- 
uterine. Paris,  1861,  p.  9. 


PELVIC  HillMOREHAGES  AND  PEEI-UTERINE  HEMATOCELE      715 

3.  The  theory  developed  by  Gallard^^  who  considers  hematocele 
an  extra-uterine  dehiscence,  an  extra-uterine  pregnancy  without  the 
product  of  conception,  has  by  no  means  been  proved.  Where  is 
the  proof  that  the  ovule  determines  hsemorrhage  on  falling  into  the 
serous  membrane  ?  As  to  hsemorrhage  due  to  extra-uterine  preg- 
nancy, it  is  possible  though  rare,  the  principal  fact  in  such  a  case  being 
the  extra-uterine  pregnancy  itself,  that  is,  Huguier's  pseudo-hema- 
tocele. 

3.  Other  writers,  including  Beau  and  Tardieu,  think  there  is  a 
sanguineous  exudation  from  the  serous  membrane  of  the  pelvis  ; 
Perber^  has  adopted  this  hypothesis,  urging  that  some  autopsies 
have  revealed  hypersemia  and  capillary  vessels  of  new  formation,  and 
that  it  is  nothing  less  than  hsemorrhagic  pelvic  peritonitis  (Yirchow). 

4.  We  have  still  another  hypothesis  to  examine,  that  put  forth  by 
Bernutz  in  1848  and  again  in  1860  ;  he  admits  that  the  lumen  of  the 
cervico- uterine  canal  may  be  closed  by  an  obstacle  depending  on  the 
contractility  of  the  uterus  and  that  the  blood  may  accumulate  in 
the  cavity  of  the  body,  after  having  dilated  which  it  enters  the 
Fallopian  tubes  and  passes  into  the  peritoneum.  There  is  no  doubt 
that  the  blood  may  follow  this  course  when  there  is  any  obstacle, 
whether  congenital  or  acquired,  in  the  vulvo-uterine  canal ;  but  it 
has  not  been  proved  that  it  may  occur  when  there  is  none.  If,  on 
the  one  hand,  the  narrowness  of  the  ostia  uterina,  their  slight  per- 
meability and  the  relatively  large  size  of  the  cervico-uterine  canal,  are 
anatomical  arguments  which  should  not  be  forgotten,  on  the  other 
hand  we  have  no  right  to  avail  ourselves  in  the  argument  of  what 
occurs  in  cases  of  atresia  of  the  genital  canal,  that  is  to  say  in  the 
conditions  most  favorable  to  the  reflex  tlieory,  as  Aran  calls  it ;  Puech^ 
has  proved  that  the  fact  is  excessively  rare;  it  only  occurred  16 
times  out  of  310  cases,  and  it  never  occurred  suddenly ;  excruciating 
suffering  was  endured  by  the  patients  for  several  years  before  the 
blood  invaded  the  peritoneal  cavity .''^  Therefore  pelvic  haemorrhages 
can  only  have  their  source  in  the  Fallopian  tube,  ovary,  utero-ovarian 
plexus,  and  in  hsemorrhagiparous  pachy-peritonitis. 

I.  Hcemorrhage  from  the  Fallopian  tube. — Indicated  by  Tilt  in 
1850  and  by  Eenerly  in  1855,  tubal  hsemorrhage  has  only  taken  its 
place  in  science  with  the  works  of  Puech.  A  sufficient  number  of 
cases  are  recorded  to  prove  that  the  Pallopian  tube  is  far  from  pos- 
sessing immunity  in  this  respect ;  but  in  all  these  cases  we  may  recog- 
nise as  a  preliminary  condition  sanguineous  congestion  of  the  tube, 
and  although  we  know  that  the  exanthemata,  such  as  measles,  small- 
pox, and  scarlet  fever,  encourage  hasmorrhages,  as  in  the  cases  seen 
by  Laboulbene,^  Helie,^  Scarizoni''  and  Puech,    we  are  incHned  to 

^  Gaz.  hebclom.,  1858,  p.  481,  Archives  de  Medecine,  1860. 

'^  ArcMv.  der  Heilkunde,  1862,  8th  year,  part  5. 

^  Des  atresies  des  voies  genitales.  Paris,  1863,  p.  61. 

■*  See  p.  279,  chapter  on  Retention  of  the  Menses. 

*  Gaz.  ined.  de  Paris,  1853,  p.  78. 

"  Journal  de  viedecine  de  la  Loire-lnferieure,  1858,  p.  80. 

'  Op.  cit.,  p.  363. 


716  UTERINE    DISEASES    IN    DETAIL 

admit  that  there  is  always  acute  fluxion  or  congestion.  At  other 
timeSj  on  the  contrary,  we  find  in  the  previous  history  symptoms  of 
chronic  sanguineous  congestion,  Bernutz's  first  case  being  a  typical 
example.^ 

Whatever  be  the  cause  which  has  produced  it,  the  hsemorrhage 
may  make  its  way  either  by  the  ostia  uterina,  by  the  abdominal  opening, 
or  by  rupture  of  the  organ.  The  discharges  of  blood  from  these 
different  points  are  sometimes  simultaneous  and  sometimes  isolated  ; 
if  they  escape  notice  when  the  fluid  is  discharged  by  the  first  exit,  it 
is  otherwise  when  the  blood  escapes  by  the  latter  channels.  The 
patient  suffers  pain  in  the  lumbo-sacral  region,  and  has  colics  suc- 
ceeded by  syncope  and  a  feeling  of  weakness.  Sometimes  these  with 
paleness  of  the  face  are  the  only  symptoms,  at  other  times,  when  the 
liEemorrhage  endangers  life,  the  pains  are  more  violent,  and  there  is 
vomiting,  hiccough,  buzzing  in  the  ears,  abdominal  distension  and 
cold  sweats,  soon  followed  by  death.  When  on  the  contrary  the 
hsemorrhage  is  not  great  enough  to  cause  this  result,  as  seen  by  Follin,^ 
Oulmont,^  Seuvre,*  and  otherSj  a  peri-uterine  sanguineous  tumour  is 
formed. 

II.  Ovarian  hemorrhage . — These  haemorrhages  are  frequently 
described.^  Here  also  a  marked  alteration  of  the  ovaries  exists  pre* 
vious  to  any  hsemorrhage  ;  apart  from  a  case  mentioned  by  Neuman, 
of  Berlin,^  in  which  hydatids  were  found,  acute  inflammation  and 
chronic  congestion  are  the  lesions  which  have  been  more  specially 
noticed.  In  acute  inflammation  the  size  of  the  organ  is  increased,  the 
colour  is  violet,  and  on  section  the  blood  gushes  out,  the  cut  surface 
showing  considerable  hypersemia.  In  this  state  the  tissues  can  neither 
resist  nor  be  distended ;  they  are  easily  ruptured,  as  remarked  by 
Denonvilliers'''  and  Demarquay.^  Chronic  congestion  is,  I  believe,  the 
most  active  cause  of  these  hsemorrhages.  The  ovary  is  increased  in 
size,  its  outline  is  normal,  but  the  stroma  is  hypersemiated,  presenting 
slight  effusions  of  blood.  As  a  rule  this  state  is  only  manifested 
externally  by  excessive  menstruation ;  at  other  times  there  is  a  sen- 
sation of  weight  and  burning  heat  in  the  pelvis,  draggings  in  the 
kidneys  and  groins,  and  colics,  which  are  sometimes  very  acute, 
before  menstruation.  Menstruation,  besides  being  too  abundant,  is 
prolonged  more  and  more,  leaving  each  time  a  marked  aggravation  of 
the  congestive  phenomena.  In  this  state  accidents  are  imminent,  and 
menstruation  is  sometimes  sufficient  to  produce  hsemorrhage;  but  it 
does  not  follow  that  there  is  a  relation  of  cause  and  effect  between 

1  Nouveau  Diction,  de  fried,  et  de  chirurg.  pratiques,  article  Hematocele 
TTTEEijsTE,  t.  xvii,  p.  310,  fig.  29.  In  this  figure  a  clot  is  seen  emerging  from 
the  Fallopian  tube. 

^  Gaz.  des  hopitaux,  1855,  p.  403. 

^  Union  medicale,  1858,  p.  530. 

*  Progres  medical,  1874,  pp.  815,  224. 

°  Nouveau  Diction,  de  med.  et  de  chirurgie  pratiques,  article  Hematocele 

UTERINE. 

*  Bibliotheque  medicals  de  Roy  er  -  Collar  d,  t.  Ixsviii,  p.  113. 
7  Gaz.  med.,  1856,  p.  76. 

*  Gaz.  des  hopita^tx,  1862,  p.  21. 


PELVIC  HiEMOREHAGES  AND  PERI-UTEEINE  HEMATOCELE       717 

the  peri-uterine  hematocele  which  may  be  developed  afterwards  and 
menstruation ;  disorders  of  this  function  are  only  the  index  of  the 
concomitant  state  of  the  uterine  system.  At  other  times  the  sym- 
ptoms are  those  of  acute  sanguineous  congestion,  apoplectic  haemor- 
rhage occurring  in  the.  midst  of  apparently  perfect  health ;  only  in 
such  cases  fluxion  is  more  active  and  the  afflux  of  blood  more  con- 
siderable. 

Whether  the  ovary  is  healthy  or  otherwise  the  haemorrhage  may  be 
intra-ovarian  only,  or  both  intra  and  extra-ovarian ;  whilst  in  the 
interesting  case  published  by  Puech  intra-ovarian  hsemorrhage  was 
followed,  four  months  afterwards,  by  fresh  congestion,  which  on  this 
occasion  ruptured  the  membrane,  causing  death  by  peritonitis.  If 
symptoms  of  intra-ovarian  hsemorrhage  often  escape  notice,  or 
at  least  are  misinterpreted,  it  is  very  different  when  hsemorrhage 
occurs  in  the  pelvis ;  in  such  cases  we  either  see  the  signs  of  inter- 
nal hsemorrhage  which  soon  ends  fatally,  or  the  physical  signs  which 
characterise  sanguineous  tumours  of  the  pelvis, 

III.  Kamonhage  from  the  utero-ovarian  plexus. — Although  analogy 
would  seem  to  indicate  the  possibility  of  rupture  of  the  utero-ovarian 
plexus,  this  source  of  hsemorrhage  has  been  slow  in  taking  the  place 
to  which  it  is  entitled.  In  vain  two  cases  of  it  were  published  in 
1853  and  1854,  even  in  1857  it  was  in  vain  that  Eichet  brought 
forward  a  new  argument  in  support  of  the  fact,^  attention  was  directed 
elsewhere,  and  it  was  only  in  1858,  in  the  works  of  Puech  ^  and 
Devalz,^  that  these  venous  lesions  obtained  the  rank  that  they  deserve 
as  causes  of  pelvic  hsemorrhage.  This  rupture  may  be  followed  by 
extravasation  of  blood  under  the  peritoneum,  and  between  the  folds  of 
the  broad  ligament  (Raciborski),  by  a  simple  intra-pelvic  thrombus  or 
by  a  more  considerable  hsemorrhage  and  a  more  or  less  abundant  san- 
guineous effusion  into  the  pelvis.  It  affects  the  pampiniform  plexus 
whether  varicose  or  not.  Doubtless  the  nodosities  presented  at  inter- 
vals by  the  varicose  veins  and  the  attenuation  of  their  walls  favour 
this  accident ;  but  unfortunately  these  conditions  are  not  indispensable 
for  its  production :  severe  exercise,  or  external  violence,  sexual  excite- 
ment, or  great  menstrual  fluxion,  or  the  concurrence  of  these  two  last 
circumstances  may  cause  the  malady.  The  hsemorrhage  which  occurs 
is  more  or  less  violent ;  in  twelve  cases  it  caused  death  rapidly;'''  in 
others,  amongst  which  Saexinger^s  case  may  be  included,^  it  was  fol- 
lowed by  the  formation  of  a  peri-uterine  hematocele.^ 

IV.  Hemorrhages  from  hamorrhagijmro^is  pachy -peritonitis. — Bes- 
nier  has  tried   to  furnish  additional  proofs  of  this   theory  in  a  long 

*  Anat.  7ned.-chirurg.,  1857,  p.  735. 
^  Op.  cit.,  pp.  80— lUO. 

^  Du  varicocele  ovarien.  Paris,  1858. 

*  In  tlie  case  recorded  by  Maschka  death  was  caused  by  the  rupture  of  a 
varicose  vein  attached  to  the  fundus  of  the  uterus  {Wiener  Medicinische  Wo- 
chenschrift,  1800,  No.  102). 

=-  Monatschriftfilr  Geburtslc,  1864,  Bd.xxiii,  S.  476. 

'  Of  the  four  sources  of  hematocele,  this  and  the  following  may  coincide 
with  regularity  of  the  menstrual  function. 


718  UTERINE    DISEASES    IN    DETAIL 

paper  published  in  1877  in  the  Annales  cle  Gynecologie,  the  conclu- 
sions of  which  are : 

"  1.  Amongst  intra-peritoneal  hematoceles  there  is  one  which  com- 
mences with  primary  or  secondary  pelvic  peritonitis^  either  menstrual 
or  inter-menstrual,  which  is  benignant  or  moderate  on  its  appearance, 
and  increases  progressively  or  by  jBts.  In  this  form  of  hematocele, 
which  is  very  different  from  those  which  commence  suddenly  and 
violently  and  end  fatally,  the  tumour,  which  is  but  a  pathognomonic 
sign  of  the  affection,  is  only  verified  at  a  late  ^^eriod  relatively  to  the 
commencement  of  the  symptoms,  and  as  a  rule  the  termination  is 
favorable.  2.  The  cases  included  in  this  group  cannot  be  regarded  as 
hematoceles  connected  with  dehiscence  or  extra-uterine  pregnancy,  nor 
with  an  ovarian  lesion,  nor  with  a  sanguineous  reflux  by  the  tubes, 
nor  with  rupture  of  the  tubo-ovarian  veins,  &c. ;  they  ought  to  be 
considered  as  hematoceles  due  to  pelvic  neo- membranes.  Taken  as  a 
whole  these  maladies  are  therefore  cases  of  peritonitis  which  have 
become  hsemorrhagic  accidentally  or  secondarily,  otherwise  called 
hemorrhagic  pachy -peritonitis.  3,  Trom  a  clinical  point  of  view,  these 
cases  being  the  most  numerous  of  all,  as  we  may  say  they  are  the  only 
hematoceles  which  end  in  cure,  it  follows  that  ordinary  intra-peritoneal 
hematocele  terminating  favorably  is,  in  most  if  not  in  all  cases,  a 
hsemorrhagic  pachy -peritonitis,  either  menstrual  or  inter -menstrual, 
usually  the  former,  that  is  to  say,  having  commenced  at  a  menstrual 
period.^' 

I  do  not  deny  the  possibility  of  hsemorrhagiparous  pachy-peritonitis. 
I  admit  this  new  source  of  hematocele  by  analogy  with  neo-membranes 
developed  on  other  serous  membranes  (meningeal,  vaginal,  synovial, 
&c.)  and  giving  rise  to  loss  of  blood  ;  but  I  am  far  from  regarding  it 
as  the  most  frequent,  as  this  would  imply  in  all  cases  the  existence  of 
previous  peritonitis,  slowness  of  the  sanguineous  efi'usion  and  a 
number  of  other  circumstances  totally  opposed  to  most  of  the  sym- 
ptoms on  which  we  found  the  diagnosis  of  hematocele.  Besnier's 
case  moreover  does  not  seem  absolutely  decisive ;  no  autopsy,  abortion 
preceding  the  hematocele,  rapidity  in  the  invasion  of  the  attack  and 
in  the  symptomatic  manifestation,  in  short,  nothing  justifying  the 
asserted  slowness  of  invasion  and  symptomatic  obscurity  of  the  com- 
mencement. My  own  conclusion  is  that,  of  the  various  sources  of 
sanguineous  effusion  which  can  account  for  the  formation  of  peri- 
uterine hematocele,  four  only  may  be  considered  as  proved  by  autopsy. 
These  are,  in  order  of  frequency  :  apoplectic  haemorrhage  from  the 
ovaries,  hsemorrhagic  pachy-peritonitis,  rupture  of  one  of  the  vessels 
composing  the  utero-ovarian  plexus  and  tubal  haemorrhage.  These 
hgemorrhages  terminate  either  fatally,  or  by  absorption  of  the  extrava- 
sated  blood,  or  by  the  formation  of  a  sanguineous  tumour  (hematocele, 
hematoma).  In  the  latter  case  the  hEemorrhage  is  the  cause,  tiie 
hematocele  the  effect ;  but  the  effect  becomes  in  its  turn  a  malady, 
having  its  symptoms,  its  course,  its  termination,  its  indications. 


PELVIC  H^MOREHAGES  AND  PERI-UTERINE  HEMATOCELE       719 


2.  Peri-TJterine  Hematocele 

Hematocele'^  is  an  encysted  tumour  developed  round  the  uterus  and 
formed  of  blood  proceeding  from  the  lesion  of  one  or  two  of  the 
appendages,  or  from  a  cyst  of  extra-uterine  pregnancy,  from  a  rupture 
of  the  utero-ovarian  plexus,  or  from  the  peritoneum  itself,  more 
frequently  from  a  chronic  inflammation  of  this  serous  membrane  with 
thickening  and  vascular  hypertrophy. 

The  various  sources  of  hsemorrhage  explain  the  seat  of  the  effusion, 
and  the  frequency  of  this  seat  in  any  particular  spot  is  the  consequence 
of  the  frequency  of  the  hemorrhage  at  that  point.  Therefore  whether 
the  hgemorrhage  come  from  the  ovary,  from  the  Fallopian  tube,  from 


Fig.  389. — Typical  retro-uterine  hematocele  (intra-peritoneal)  caused  by  rupture 
of  a  diseased  ovary,  a,  hematocele  ;  u,  uterus  pushed  forward ;  R,  rectum 
compressed  behind  (St.  Thomas's  Museum,  Barnes). 

an  extra-uterine  pregnancy  or  from  pachy-peritonitis,  the  sanguineous 
effusion  must  take  place  into  the  peritoneal  cavity  (which  is  the  most 
common  case),  preferably  behind  the  uterus,  where  the  serous  mem- 
brane is  most  developed ;  the  ovaries  are  also  to  be  found  there  and  the 
Fallopian  tubes  always  directed  backwards  and  never  forwards  (on  this 
account  hematocele  is  more  frequently  retro-uterine  than  peri-uterine). 
This  rule  is  so  general  that  ante-uterine  hematocele  is  considered  as 
being  only  secondary,  formed  only  as  a  consequence  of  the  peri-uterine 
or  retro-uterine  hematocele  which  has  preceded  it,  the  continuation  of 
which  has  become  impossible  owing  to  adhesions  and  fibrous  bands 

^  Poncet  of  Itjons,  De  Vheniatochle  peri-uterine.  These  d'agr^gation.  Paris, 
1878. 


720 


UTEEINE    DISEASES    IN    DETAIL 


uniting  the  uterus  to  the  rectum  and  sacrum  so  as  to  prevent  the  con- 
tinuation of  any  sanguineous  effusion  into  Douglas's  space.  Such  is 
the  case  published  by  Schroeder  in  Wiener  Medicin.  Wochenschrift, 
1873  ;  and  in  ArcUvfur  Gyn.,  1873. 

If  the  hsemorrhage  come  from  the  tubo-ovarian  plexus  the  hemato- 
cele may  be  limited  to  a  thrombus  of  the  broad  ligament  or  be  in- 
sinuated under  the  peritoneum  covering  the  uterus,  in  the  peri-uterine 
cellular  tissue^  not  only  behind  and  in  the  broad  ligament  of  the  other 
side,  but  also  in  front  under  the  peritoneal  fold  which  covers  the  an- 
terior wall  of  the  uterus  and  bladder.     These  sanguineous  effusions 


\'i   ■ 


/*i^  Hi/7 


Fig.  390. — Lateral  and  ante-uterine  iematocele  (intra-peritoneal),  due  to 
utero-rectal  adhesions  in  Douglas's  space,  where  the  hematocele,  which  at 
first  was  retro-uterine,  was  first  produced,  aaaa,  solid  blood  and  adhe- 
sions ;  h  b,  fluid  blood  ;  d,  extra-uterine  tubal  pregnancy,  cause  of  the 
hematocele  ;  from  Schrceder  {Archiv.fur  Gyn.,  Bd.  v,  S.  357.  Berlin,  1873). 

into  the  broad  ligament  and  peri-uterine  connective  tissue  have  been 
well  nsimed peri-titerine  hematomata  by  Kuhn  (These  de  Zurich,  1874), 
a  name  which  distinguishes  this  sanguineous  tumour  from  hematocele 
which  is  in  the  peritoneum  and  from  hematometria  which  is  in  the 
uterus,  a  name  very  preferable  to  that  of  extra-peritoneal  or  vaginal 
hematocele,  by  which  it  was  formerly  designated.  The  blood  is  gra- 
dually absorbed  and  the  most  frequent  termination  is  in  cure.  The 
prognosis,  however,  is  more  unfavorable  than  in  the  case  of  hemato- 
cele, for  this  reason,  that  the  opening  of  the  tumour  into  the  peri- 
toneum is  very  dangerous,  usually  causing  death.  I  copy  a  figure 
(from  Emmet)  of  a  very  rare  case  of  such  a  hematocele  or  hematoma 
formed  in  the  right  broad  ligament  and  in  front  of  the  bladder,  which 
caused  death  by  its  rupture  into  the  peritoneum  (Fig.  392). 

Whatever  be  the  source  of  the  hsemorrhage  and  wherever  the  blood 
may  be  effused  it  is  not  long  before  it  undergoes  certain  modifications 


PELVIC  H^MOEEHAGBS  AND  PERI-UTERINE  HEMATOCELE      721 

producing  around  it  an  interesting  pathological  process.  The  blood, 
which  at  first  is  liquid^  soon  coagulates  into  more  or  less  voluminous 
resistant  clots,  the  presence  of  which  irritates  the  serous  membrane 
with  which  it  is  usually  in  contact;  false  membranes  are  produced; 
some  which  are  filamentous  pass  above  the  sanguineous  mass,  others 
resembling  bands  of  cellular  tissue  divide  the  collection  by  forming 
partitions  through  it.  At  other  times  there  are  no  fibrous  adhesions 
but  a  kind  of  membranous  covering,  which,  spreading  like  a  sheet, 
seems  to  form  a  continuation  of  the  peritoneum  and  has  frequently 
been  taken  for  it.  In  other  cases  this  is  absent  and  the  intestinal 
loops,  united  and  glued  together,  constitute  the  upper  wall  of  the 
cyst.  When  the  adhesions  are  detached  we  penetrate  into  a  winding 
sac  sometimes  containing  from  7  to  77  ounces  of  a  wine-coloured 
viscous  fluid  holding  dark  clots  in  suspension,  or  when  the  malady  is 
of  longer  standing  a  yellowish  or  more  or  less  discoloured  fibrinous 
mass.  The  bladder,  rectum  and  upper  extremity  of  the  vagina  are 
compressed ;  when  there  has  been  suppuration  and  evacuation  of  pus 
the  walls  of  the  rectum  or  vagina  are  perforated,  either  simultaneously 
or  singly.  The  uterus,  dragged  down  by  adhesions  and  inclined  to  the 
right  or  left,  has  in  some  cases  effected  rotation  on  its  axis,  in  others  it  is 


Fig.  391. — Sub-peritoneal  latevo  and  retro-uterine  liematoma  or  hematocele 
(extra-peritoneal)  formed  in  the  broad  lig-ament.  The  posterior  vaginal 
wall  was  still  more  pushed  forward  (after  Emmet). 

inclined  forwards  or  backwards  without  being  fixed  in  its  position.  As 
it  usually  shares  in  the  congestion  of  which  the  annexes  are  the  seat, 
it  is  more  frequently  increased  in  size  ;  its  walls  may  be  softened  and  in- 
filtrated with  blood,  the  cavity  containing  either  mucous  or  sanguineous 
clots.  The  annexes  are  more  or  less  changed  :  if  there  are  cases  in  which 
we  can  discover  the  source  of  the  haemorrhage,  there  are  others  in  which 

46 


722 


UTERINE    DISEASES   IN    DETAIL 


we  can  only  guess  at  it.  Thus  the  ovaries,  or  at  least  one  of  them,  may 
be  reduced  to  a  shell;  at  other  times  they  are  hypertrophied  and  hollowed 
out  into  a  cavity  communicating  with  the  principal  centre.  In  other 
cases  or  even  simultaneously  the  tubes  have  their  fimbriated  extremity 
and  canal  partly  obliterated ;  or  else  they  are  diseased,  contaiaing  de- 
composed blood  or  presenting  a  dilatation  which  constitutes  a  part  of 
the  centre  of  the  tumour. 

Besides  these  lesions  we  find  others  dependent  on  the  general- 
ised peritonitis  or  on  purulent  infection.  In  the  former  case  the 
abdominal  viscera  bear  the  more  or  less  marked  impress  of  in- 
flammation. The  intestines  are  shortened  sometimes  to  half  their 
length,  whilst  some  circumvolutions  are  drawn  together  and  united 
by  false  membranes.  Sometimes  the  abdominal  cavity  is  dis- 
tended by  a  yellowish  serum  or  by  a  milky  fluid  mixed  with  albumi- 
nous flakes ;  sometimes  there  is  hardly  any  effusion,  but  the  roughened 
serous  membrane  presents  patches  of  a  blackish  hue ;  lastly,  if  the  cyst 
has  been  perforated  and  the  contents  have  escaped  we  may  find  a  portion 
of  this  fluid  pour*?d  out  into  the  peritoneal  cavity.  As  to  purulent 
infection  it  leaves  behind  it  well-known  lesions  on  which  it  is  needless 
here  to  dwell. 


Fig.  392. — Sub-peritoneal  ante-uterine  hematoma  or  hematocele  (very  rare) 
opened  by  laceration  or  ulceration  into  the  peritoneum,  where  the  blood 
has  been  effused  and  has  formed  an  intra-peritoneal  peri- uterine  hematocele 
which  was  the  cause  of  death  (after  Emmet). 

Diagnosis — subjective  signs. — Peri-uterine  hematocele  being  a  hae- 
morrhage followed  by  peritonitis  we  should  find  in  its  first  stage  the 
characteristic  symptoms  of  internal  hcemorrhage  :  they  exist  in  fact ; 
but  as  they  are  obscure  they  generally  escape  observation.  The  period 
which  follows   and  of  which  the  features  are  borrowed  from  peritonitis, 


PELVIC  HiEMOREHAGES  AND  PERI-UTEEINE  HEMATOCELE      723 

is  more  marked,  although  it  does  not  offer  any  very  striking  symptoms  : 
hence  the  possibility  of  committing  errors  of  diagnosis.  Pain  is  the 
first  phenomenon  which  shows  itself :  it  is  constant,  but  it  varies  greatly 
in  intensity.  It  is  sometimes  manifested  under  the  form  of  intestinal 
colics,  sometimes  under  that  of  expulsive  pains.  It  is  often  remittent, 
but  is  aggravated  by  the  least  pressure  or  by  the  slightest  movement. 
Disorders  of  the  digestive  economy  are  intimately  connected  with  these 
pains  :  when  the  latter  are  intense  there  is  nausea  and  vomiting  ;i  if 
they  are  moderate  there  is  frequently  want  of  appetite.  Thirst  is 
generally  great,  the  abdomen  is  more  or  less  distended,  and  there  is 
usually  obstinate  constipation,  anal  and  sometimes  also  vesical  tenesmus, 
and  even  retention  of  urine.  When  the  tumour  compresses  the  crural 
and  sciatic  nerves  radiating  pains  and  numbness  are  observed  in  the 
lower  limbs.  OEdema  has  also  been  seen  in  addition  to  the  preceding 
symptoms,  affecting  either  the  side  corresponding  to  the  largest  portion 
of  the  pelvic  tumour  or  the  opposite  one ;  in  the  former  case  it  would 
be  due  to  impeded  venous  circulation,  in  the  second  to  phlebitis  of  the 
corresponding  veins. 


Fig.  393. — Peri-uterine  hematocele  spreading  uniformly  round  the  uterus,  which 
has  hardly  undergone  any  displacement.  Owen's  case,  University  College 
Hospital,  1866.     Front  view  (after  Graily  Hewitt). 

Objective  signs. — The  seat  of  pain  and  the  distension  of  the  belly 
attract  the  attention  of  the  physician  to  the  hypogastric  region  and 
enable  him  to  verify  the  existence  of  a  peri-uterine  tumour.  Sometimes  it 
is  diagnosed  immediately  on  account  of  the  projection  and  the  size  which 
it  presents  ;  at  other  times  it  is  only  discovered  after  careful  palpation. 
Two  tumours  are  then  found  in  the  pelvic  cavity  :  the  anterior  one  is  the 
uterus,  the  other,  posterior  and  more  or  less  lateral, is  the  morbid  tumour, 
the  hematocele.  The  size  of  the  latter  varies  from  that  of  an  apple  to 
a  child's  head.  It  is  usually  confined  to  the  pelvis,  but  may  rise  above 
the  brim  towards  the  umbilicus ;  I  do  not  think,  however,  that  it  ever 
rises  beyond  the  navel  :  observers  who  have  mentioned  such  cases  have 

'  There  may  even  be  symptoms  of  internal  strangulation  as  Hergott  has 
remarked ;  they  seem  caused  by  an  anomaly  of  the  sigmoid  flexure  {Mem.  Soc. 
met.  Strasbourg,  1872,  p.  149). 


724 


UTERINE    DISEASES   IN    DETAIL 


forgotten  to  take  into  account  the  inflammatory  zone,  which  has  led 
them  into  error.     As  to  the  consistency  of  the  tumour,  it  may  be 


Fig.  394. — Intra-peritoneal  peri-uterine  hematocele,  seen  in  profile,  spread 
uniformly  round  and  above  the  uterus,  which  has  not  been  displaced  at  all 
(after  Emmet). 

fluid  and  fluctuating;  but  unless  it  suppurates  it  becomes  solid,  hard 
and  immobile.  Diagnosed  in  the  abdomen  by  hypogastric  palpation, 
in  the  pelvis  the  tumour  is  defined  by  vaginal  touch ;  it  is  found  behind 
and  at  the  sides  of  the  uterus ;  in  three  cases  it  extended  in  front  of 
this  organ ;  in  a  case  published  by  Chassaignaci  it  was  situated  entirely 
between  the  bladder  and  uterus.  Usually  it  pushes  down  the  posterior 
cul-de-sac,  contracting  the  vagina.  Eectal  examination  reveals  the 
compression  which  it  exercises  on  the  intestine,  making  it  difficult  for 
the  finger  to  penetrate  the  canal.  The  uterus  is  pushed  forwards  and 
upwards  against  the  pubis,  the  neck  under  the  pubic  arch,  sometimes 
in  the  median  line,  sometimes  a  little  to  the  right  or  left :  it  is  fixed 
in  this  position.  Left  to  itself  the  tumour  at  first  remains  stationary ; 
but  sometimes  it  presents  alternations  of  tension  and  relaxation  which 
depend  chiefly  on  the  increase  or  diminution  of  the  inflammatory  phe- 
nomena. This  increase  lasts  for  some  days ;  then  the  tumour 
diminishes  in  size  and  gradually  enters  the  pelvic  cavity,  where  it 
remains  finally  concealed.  Erom  being  soft  and  puffy  at  the  com- 
mencement the  hematocele  becomes  as  hard  as  wood ;  it  contracts 
from  the  circumference  to  the  centre  more  or  less  rapidly  according 
to  the  case.  Occasionally  numerous  inflammatory  accidents  are  de- 
veloped, sometimes  in  the  neighbouring  peritoneum,  sometimes  in  the 

1  Traite  de  la  suppuration,  t.  ii,  p.  463. 


PELVIC  HAEMORRHAGES  AND  PERI-UTERINE  HEMATOCELE       725 

cumour  itself;   febrile  symptoms  aud  slight  shivering;  in  the  evening 
indicating  that  suppuration  is  going  on  in  the  cyst.     The  clots  of 


Fig.  395. — Intra-peritoneal  retro-uterine  hematocele  H,  which  has  pushed  the 
uterus  upwards,  v  rr  u'  u",  and  forwards  (after  Barnes). 

blood  become  softened  and  disintegrated  and  assume  a  black  and  after- 
wards a  greyish  hue ;  pus  is  formed  and  tends  to  be  evacuated ;  once  pro- 


Fia.  396. — Intra-peritoneal  retro-ntcrine  hematocele,  extending  to  the  base  of 
the  pelvic  cavity  from  Douglas's  pouch,  pushing  the  uterus  u  upwards 
and  forwards,  flattening  the  cervix  against  the  pubis,  and  compressing  the 
bladder  v',  seen  in  profile  (after  Barnes). 

duced,  this  fluid  either  pierces  the  cyst  on  the  side  of  the  serous  mem^ 


726 


UTEEINE    DISEASES  IN   DETAIL 


brane  and  sets  up  peritonitis  which  soon  ends  fatally ;  or  else  making 
its  way  towards  the  cellular  tissue  it  succeeds  in  emptying  itself  more 
or  less  completely  either  by  the  vagina  or  by  the  rectum. 

Although  evacuation  of  the  contents  of  the  tumour  into  the  perito- 
neum always  ends  fatally  it  is  quite  otherwise  with  the  other  two  modes 
of  exit.  They  are  both  favorable,  although  less  so  than  resolution  of 
the  tumour  :  they  are  usually  attended  by  diminution  in  the  size  of  the 
tumour  and  by  marked  alleviation ;  they  are  accompanied  by  a  dis- 
charge somewhat  like  treacle  or  sepia  ink,  which  may  cease  in  two  days, 
but  which  usually  persists  from  ten  days  to  a  fortnight.  The  escape 
of  blood  and  pus  by  the  vagina  has  almost  always  been  followed  by 
1     When  the  tumour,  on  the  contrary,  opens  into  the  rectum  the 


cure. 


little  wound  may  remain  fistulous,  and  the  intestinal  gases  may  pene- 
trate into  the  interior  of  the  mass,  causing  hectic  fever  and  a  kind  of 
putrid  infection.  To  sum  up,  out  of  52  cases  in  which  the  tumour 
was  left  to  itself  absorption  occurred  26  times,  evacuation  of  the  con- 
tents into  the  peritoneum  6  times,  by  the  rectum  13  times  and  by  the 


vagina  7  times 


Differential  diagnosis. — The  diagnosis  of  peri-uterine  hematocele  is 
easy  from  the  beginning :  the  rapid  appearance  of  the  tumour,  the 
concomitant  symptoms,  of  which  the  most  marked  are  those  of  peri- 
tonitis, the  displacement  of  the  pelvic  organs,  the  cervix  being  squeezed 
under  the  pubis  and  the  uterus  pushed  forwards,  the  flattening 
of  the  rectum  and  the  consistency  of  the  tumour  are  all  data  upon 


Fig.  397.— Pelvic  peritonitis  and  pelvic  abscess,  seen   in   profile,   recognised 
tlirougli  the  vagina  (after  Graily  Hewitt). 

which  to  form  a  certain  diagnosis.     It  is  not,  however,  always  so : 

time  may  have  modified  the  symptoms,  rendering  them  less  marked,  so 

1  Ott  {Dissert,  de  Tubingen,  1864)  tas  seen  a  case  of  death  from  septicaemia 

under  these  conditions. 


PELVIC  HililMOEEHAGES  AND  PEEI-UTEEINE  HEMATOCELE     727 

that  the  ablest  physicians  have  sometimes  been  deceived  and  have 
mistaken  hematocele  for  perimetritis^  extra-uterine  pregnancy,  a  cyst 
or  some  other  tumour  of  the  ovary  or  tube,  a  fibroid  tumour,  retro- 
flexion, &c.  Peri-uterine  inflammation  is  one  of  the  diseases  as  to 
which  we  may  be  easily  mistaken  :  but  apart  from  the  symptoms  common 
to  the  two  diseases  there  are  radical  differences  :  at  the  beginning  the 
low  temperature  (37'5°)  distinguishes  hematocele  horn  pelvic  cellulitis 
(38-1°)  and  from  parenchymatous  metritis  (39"5°);^  pelvic  abscess  is 
almost  always  connected  with  delivery  or  abortion,  whilst  hematocele 
is  very  rarely  the  result  of  these,  being  rather  connected  with  men- 


FiG.  398. — Circumscribed  and  encysted  pelvic  cellulitis.  Outline  of  the  pelvic 
abscess  (phlegmon  of  the  broad  ligament)  to  the  right  of  the  uterus. 
Case  in  University  College  Hospital,  seen  in  profile  (after  Graily  Hewitt). 

strual  disorders ;  the  former  is  developed  slowly,  the  latter  suddenly, 
reaching  its  maximum  of  development  in  a  few  hours ;  when  digital 
touch  is  practised  the  one  gives  the  sensation  of  a  kind  of  hard  puffi- 
ness  which  is  never  fluctuating  or  is  only  so  towards  the  end,  the  other 
is  only  fluctuating  at  the  commencement,  and  becomes  hard  as  the 
effusion  is  absorbed ;  in  fact  the  abscess  seems  to  make  one  mass  with 
the  uterus,  never  producing  displacements  analogous  to  those  caused 
by  sanguineous  effusion,  which  is  distinct  from  the  womb,  the  latter 
being  pushed  more  or  less  out  of  place ;  it  never  acquires  so  large  a 
size,  and  is  comparatively  long  in  being  cured. 

In  adhesive  suppurative  pelvic  peritonitis  \)iit  distinction  is  still  more 
difficult.  Pelvic  peritonitis  often  extends  all  round  the  uterus,  the 
annexes  and  pelvis,  like  peri-uterine  hematocele ;  but  usually  it  does 
not  descend  so  low  and  often  rises  higher,  above  the  brim ;  like  hema- 
tocele, it  fixes  the  uterus,  but  as  it  extends  more  equally  round  this 

'  Ai-melli,  Movimento  7ned.  chirurg.  de  Naples  (Annales  de  Gynecologie, 
ix,  159). 


728 


UTEEINE   DISEASES    IN   DETAIL 


organ  it  displaces  it  less  frequently  and  less  considerably.  When  the 
malady  is  of  long  standing  and  its  development  has  not  been  followed, 
the  diflBculties  of  diagnosis  are  still  greater,  and  can  only  be  overcome 
by  analysing  the  antecedent  history  carefully.  Extra-uterine  preg- 
nancy is  developed  slowly  and  often  without  any  appreciable  functional 
reaction,  whilst  usually  hematocele  begins  suddenly,  reaching  its 
maximum  of  development  all  at  once.  But  the  diagnosis  is  difficult 
when  rupture  of  the  fcetal  cyst  has  caused  hsemorrhage  and  produced 
a  tumour  analogous  to  hematocele :  in   such  a  case  as  a  rule  the 


Fig.  399. — Extra-uterine  pregnancy,  mistaken  at  first  for  retroflexion  of  a 
gravid  uterus,  diagnosed  only  by  means  of  the  sound.  Cervix  directed 
downwards  and  backwards,  the  reverse  of  retroversion  and  flexion. 
Puncture  of  the  cyst,  vaginal  and  rectal  opening.  Expulsion  of  small 
bones,  contraction  of  the  cyst.  Cure  {Annalesde  Gynecologie,  after  Barnes). 

diagnosis  is  posthumous,  unless  spontaneous  opening  of  the  tumour 
and  expulsion  of  foetal  fragments  put  the  practitioner  on  the  right 
track. 

Retroversion  and  retroflexion  of  the  uterus,  especially  in  the  third 
month  of  pregnancy,  may  be  mistaken  for  hematocele,  as  mentioned  by 
Jourel,^  Penerly^  and  Mikschik.^  Puech  has  recently  seen  a  case 
which  had  been  mistaken  first  for  imminent  miscarriage  and  afterwards 
for  retroversion  of  the  uterus ;  the  escape  by  the  vagina  of  a  brownish 
fluid  proved  that  he  had  been  right  in  diagnosing  peri-uterine  hema- 

*  Bulletin  de  la  Faculte  de  medecine  de  Paris,  1812,  No.  8. 
2  Op.  cit.,  p.  40. 

'  De  lapathol.  des  ovaires.  Leipsic,  1856,  in  Canstat's  JahresbericM,  1856, 
p.  425. 


PELVIC  H^MOREHAGES  AND  PERI-UTERIXE  HEMATOCELE       729 

tocele.     Stoltzi  has  published  a  case  in  which  he  made  the  mistake  of 
diagnosing  an  extra-uterine /(5roir/  tumour.    In  other  cases  it  has  been 


Tig.  400.— Eetro-flexion  o£  the  gravid  uterus.  Cervix  close  to  the  pubis,  di- 
rected  downwards  and  forwards.  Fundus  thrown  backwards  towards  the 
perineum  (after  Barnes). 


Fig.  401. — Fibroma  projecting  from  the  posterior  wall  of  the  uterus  and 
compressing  the  rectum. 

Engelhardt,  Thtse  de  Strasbourg,  1856,  No.  364. 


730 


UTEEI^"E    DISEASES    IN    DETAIL 


difficult  to  distinguish  hematocele  either  from  a  hydatid  cyst  of  the 
pelvis  or  from  an  ovariati  cyst  fallen  into  the  retro-uterine  cul-de-sac. 


Fia  402. — Outline  of  the  abdominal  tumour  in  ovarian  dropsy  (after  Graily 

Hewitt). 

When  the  cyst  occupies  its  usual  place  it  is  too  independent  of  the 
pelvic  cavity,  acquires  too  large  a  size  and  is  too  spheroidal  in  form 
not  to  be  easily  distinguished  from  hematocele. 

The  following  table  gives  a  resume  of  the  principal  elements  of  the 
differential  diagnosis : 


Phlegvion  of  the  broad  ligament  and 
swppurative  pelvic  peHtonitis] 

Connected  witli  delivery,  abortion,  or 
any  other  inflammation  of  the  geni- 
tal economy. 

Phlegmon,  a  tumour  of  moderate  size, 
not  displacing  the  cervix,  often  at 
the  side,  fonned  after  the  com- 
mencement of  symptoms,  hard  at 
first  and  very  sensitive,  gradually 
softening  and  becoming  fluctuating. 

Pelvic  peritonitis  rises  above  the  brim, 
not  displacing  the  fixed  uterus  to 
any  gi'eat  extent. 

General  symptoms,  continuing  till  the 
pus  makes  a  way  of  escape  for 
itself. 


hematocele 

Unconnected  with  any  of  these  cir- 
cumstances, and  manifested  at  other 
periods  than  those  of  deliveiy. 

Large  tumour,  pushing  fonvards  the 
cervix  behind  which  it  is  situated, 
f  oi-med  at  the  commencement  of  the 
disease,  soft  at  first,  not  sensitive, 
hardening  with  time  and  losing  the 
character  of  fluctuation,  descending 
to  the  lowest  portion  of  the  cavity 
and  displacing  the  flxed  uterus  to  a 
great  extent. 

General  symptoms,  diminishing  after 
a  few  days,  long  before  the  temii- 
nation  of  the  malady. 


PELVIC  H^MOEEHAGES  AND  PEEI-UTEEINE  HEMATOCELE     731 


Extra-uterine  pregnancy 

Proceeds  slowly. 

At  first  no  functional  disorder,  after- 
wards the  disorders  of  normal  preg- 
nancy. 

Fcetal  sounds,  foetal  movements. 

Sometimes  amenorrhoea,  sometimes  re- 
gular menstruation,  but  no  metror- 
rhagia. 

Retroflexion  and  retroversion 

In  the  state  of  vacuity :  slow  develop- 
ment, no  diminution  in  size. 

In  the  gravid  state :  symptoms  of 
pregnancy. 

Fibroid  tumours 

Development  slow,  always  increasing. 
Sometimes  occur  at  the  time  of   the 

menopause. 
Amenorrhoea,  abundant  leucorrhoea  or 

metrorrhagia. 
Nodulations,  density  unequal. 
Softening  rare. 


Ovarian  cysts 
very    slow, 


Development 

limited. 
No  symptomatic  disorders. 
Tumour  at  first  fluctuating,  and  then 

hard. 

Extra-peritoneal  hematocele 
(Hematoma) 

Tumour  descending  into  the  recto- 
vaginal septum. 

Uterus  pushed  upwards  and  forwards, 
more  distinct  from  the  abnormal 
tumour. 

Violet  colour  of  the  vaginal  cul-de- 


Hematocele 

Commences  suddenly. 
General  symptoms  more  or  less  serious 
from  the  beginning. 

Results  from  auscultation  nil. 
Menstrual   disorders   coinciding   with 
metrorrhagia. 


The  uterus  and  tumour  mutually  in- 
dependent. 


Rapid  development,  subsequent  dimi- 
nution, always  in  the  period  of 
sexual  activity. 

Menstruation  and  metron-hagia. 

Regularity  of  outline,  density  equal. 
Softening  frequent. 


but     un-      Rapid  evolution  followed  by  decrease. 


General  symptoms  more  or  less  serious. 
Tumour  always  fluid  and  fluctuating. 

Intra-peritoneal  hematocele 

Tumour  higher  up,  projecting  at  the 
sides  and  behind  the  uterus. 

Uterus  fixed  (in  varying  directions)  so 
that  it  cannot  be  raised. 

No  discoloration,  frequent  paleness  of 
the  mucous  membrane. 


It  will  be  seen  that  a  sanguineous  tumour  of  the  pelvis  is  easily 
diagnosed  if  due  attention  is  paid,  but  it  is  often  very  difficult  to  say 
what  has  been  the  source  of  the  hgemorrhage. 

Treatment. — Peri-uterine  hematocele,  although  not  to  be  compared 
in  gravity  with  peri-uterine  phlegmon,  is  yet  a  serious  affection.  It 
not  only  places  life  in  danger  and  requires  long  continued  treatment 
and  rest,  but  it  also  leaves  adhesions  which  may  prevent  conception. 
Or,  even  admitting  the  possibility  of  conception,  there  would  be 
reason  to  fear  that  these  adhesions  might  become  causes  of  abortion. 
Therefore  the  prognosis  is  always  grave.  Hematocele  is  not  always 
fatal,  but  it  is  always  serious,  the  intra-peritoneal  form  more  so  than 
the  extra-peritoneal.  Eecamier's  treatment  of  hematocele  consisted  at 
first  in  puncture  of  the  tumour  by  the  vagina ;  but  ha3morrhage  having 
occurred  in  one  of  Malgaigne's  patients  and  symptoms  of  purulent 


732  UTERINE   DISEASES    IN    DETAIL 

infection  in  other  cases^  this  physician  gradually  abandoned  the 
operation.  Nelaton,  who  had  adopted  it  in  principle,  was  the  first 
to  restrict  its  application,  only  employing  it  in  cases  in  which  the  tumour 
was  liquid,  and  in  which  the  pains  were  very  intense.  This  opinion 
has  been  adopted  universally.  Seyfert^  of  Prague  has  only  once 
resorted  to  puncture  out  of  66  cases  that  he  has  treated  in  four  years. 
Although  I  do  not  recommend  puncture  by  the  vagina^  unless  capillary 
puncture  be  attempted,  it  should  be  performed  when  necessary :  the 
surgeon  being  placed  in  front  of  the  patient,  the  left  index  and  middle 
fingers  are  introduced  into  the  vagina  and  applied  to  the  most 
projecting  part  of  the  tumour.  The  cannula  of  the  trocar  is  placed 
between  the  two  fingers  and  kept  against  the  tumour ;  the  stylet  is  then 
introduced  into  the  cannula  with  the  right  hand  and  plunged  into  the 
cyst.  The  stylet  is  then  withdrawn  and  the  fluid  allowed  to  escape,  or 
it  may  be  drawn  off  by  aspiration  before  the  cannula  is  withdrawn ; 
injections  should  not  be  used  unless  they  become  necessary. 

As  our  knowledge  of  these  tumours  has  increased,  medical  treatment 
has  more  and  more  usurped  the  place  of  surgical  treatment,  which  is  a 
subject  for  congratulation.  If  we  remember  that  hcBmorrhage  always 
precedes  sanguineous  tumours  of  the  pelvis  and  that  peritonitis,  more  or 
less  circumscribed,  is  the  consequence  and  that  suppuration  may  ensue, 
we  may  deduce  from  these  data  the  principal  therapeutical  indications 
[hemostatic  antiphlogistic  treatment).  If  we  knew  the  exact  moment 
of  the  hEemorrhage  we  could,  by  the  application  of  ice  to  the  hypogas- 
tric region,  and  by  the  use  of  perchloride  of  iron,  ergot  and  other 
astringents  internally,  arrest  its  course  and  so  avoid  the  formation  of 
large  hematoceles.  These  therapeutical  means  might  be  applied  even 
when  the  hsemorrhage  seems  to  be  arrested,  being  suspended  only  when 
symptoms  of  peritoneal  inflammation  make  their  appearance.  If  peri- 
tonitis is  developed,  leeches  should  be  applied  (from  15  to  25),  either 
on  the  side  of  the  abdomen  corresponding  to  the  tumour,  or  at  the 
anus,  but  in  the  latter  case  the  number  should  be  small,  and  the 
application  should  be  repeated  the  next  day ;  or  they  may  even  be 
applied  to  the  cervix  or  on  that  part  of  the  tumour  which  projects  into 
the  vagina.  Opium  should  be  given  in  large  doses  either  by  the  rectum 
or  mouth  (three  to  four  grains  in  the  24  hours) .  The  state  of  the 
bladder  should  be  inquired  into,  for  there  is  often  tenesmus  and 
sometimes  retention  of  urine.  In  the  latter  case  the  catheter  should 
be  used  (a  gum-elastic  one  is  the  most  suitable,  as  it  accommodates 
itself  more  readily  to  the  torsion  undergone  by  the  urethra).  If 
peritonitis  is  accompanied  by  repeated  vomiting,  recourse  should  be 
had  to  anti-emetics  (seltzer-water,  ice,  belladonna,  &c.)  associated  with 
blisters  on  the  hypogastrium,  mercurial  preparations  (calomel  in  small 
doses  and  frictions  with  mercurial  ointment) ;  but  as  a  rule  it  is  well 
to  reserve  these  means  till  pain  has  ceased  and  the  tumour  has  a  ten- 
dency to  resolution.  Mild  purgatives  such  as  castor-oil  or  magnesia 
are  useful  in  overcoming  the  constipation  kept  up  by  compression  of 
the  rectum.  Belladonna  should  also  be  substituted  for  opium  as  it 
^  Saexinger,  Spitalszeitung,  1863,  Xos.  43 — 45. 


OVAEIAN  CYSTS  733 

exercises  a  different  action  on  the  intestines.  Eest  in  bed^  fomentation, 
sedative  cataplasms^  spare  diet,  are  necessary  adjuvants  in  serious  cases; 
in  simple  cases  they  alone  suffice  to  effect  a  cure.  When  the  tumour 
has  a  tendency  to  suppurate  and  there  is  slight  erratic  shivering, 
sulphate  of  quinine  is  useful.  When  there  is  pus,  the  strength  should 
be  kept  up  by  good  wine,  bark  and  iron,  associated  with  wholesome 
and  nourishing  diet.  By  these  means  it  is  possible  to  cure  hematocele 
and  to  prevent  purulent  infection  which  is  greatly  to  be  feared  when 
the  tumour  opens  into  the  rectum.  To  sum  up,  prophylactic  treatment 
consists  in  preventing  pelvic  haemorrhage,  in  putting  the  patient  on 
her  guard  against  everything  that  could  have  a  tendency  to  increase 
menstruation  or  to  suspend  it  suddenly. 

Curative  treatment  may  be  either  medical  or  surgical. 

Medical  treatment  is  most  successful.  The  following  are  the 
principal  indications  :  1,  to  moderate  sanguineous  fluxions  and  arrest 
the  hsemorrhagic  molimen ;  2,  to  subdue  the  symptoms  of  partial  peri- 
tonitis which  almost  invariably  occur  at  the  commencement  of  hemato- 
cele; 3,  to  promote  and  increase  absorption;  4,  to  modify  the  secreting 
peritoneal  irritation,  confining  it  within  the  limits  necessary  for  the 
resolution  of  the  clot  and  the  absorption  of  its  elements  ;  5,  to  prevent 
or  moderate  the  exacerbations  which  are  manifested  at  the  menstrual 
period ;  6,  to  tonify,  even  by  the  use  of  preparations  of  iron,  in  order 
to  promote  absorption  and  avoid  purulent  infection. 

Surgical  treatment  is  only  applicable  to  extra- peritoneal  hemato- 
mata  or  hematoceles  (Nonat)  and  to  intra-peritoneal  encysted  hemato- 
celes which  threaten  to  rupture  and  pour  out  their  contents  above  the 
pelvis,  causing  fatal  peritonitis  (Nelaton).  It  may  be  indicated  by 
the  large  size  of  the  tumour,  the  compression  of  the  neighbouring 
organs,  the  imminence  of  rupture,  the  acuteness  of  the  pain,  the  gravity 
of  the  reaction.  Puncture,  in  place  of  being  made  by  the  abdomen, 
hypogastrium  or  rectum  ought  to  be  performed  through  the  vagina.  A 
simple  trocar  or  capillary  aspirator,  a  bistoury  and  lithotome  may  be 
substituted  for  the  pharyngotome  employed  by  Recamier,  for  Nonat^s 
lancet  trocar,  Robertas  flat  trocar,  &c.  To  empty  the  cyst,  to  extract 
the  clots  contained  in  it,  to  make  detersive  injections,  and  to  fill  the 
vagina  with  an  india-rubber  bladder  :  such  are  the  means  for  prevent- 
ing purulent  infection. 


Cysts  of  the  Ovary  and  Genito-Pelvic  Tumours 
1.   Ovarian  Cysts 

Ovarian  cysts  are  tumours  which  may  acquire  a  considerable  size, 
formed  as  the  name  indicates  by  one  or  several  membranous  sacs  of 
various  dimensions,  developed  in  most  cases  at  the  expense  of  the 
ovarian  tissue  and  distended  by  a  fluid  of  variable  consistency  and 
composition.  They  are  developed  very  frequently  even  when  they  do 
not  constitute  the  original  disease  of  the  ovary,  in  virtue  of  the  law  by 


734  UTEEINE    DISEASES    IN    DETAIL 

which  there  is  a  more  or  less  marked  predisposition  in  all  our  organs 
to  the  formation  of  morbid  products  resembling  the  normal  structure. 

From  the  pathological  point  of  view  cysts  may  be  divided  into 
simple  and  compound^. 

Their  structure  and  composition  vary  in  the  different  kinds  of 
cysts  according  as  they  are :  1,  uni-locular,  2,  multiple  and  multi- 
locufer,  3,  mixed  or  composite. 

1.  tfni-locular  cysts. — The  structure  of  the  sac  is  usually  very 
simple :  there  are,  however,  three  membranes.  The  peritoneum 
forms  the  external  envelope.  Then  comes  a  fibrous  tunic,  which 
is  sometimes  thin  and  transparent,  at  other  times  thick  and  formed 
of  fibrous  tissue;  this  tunic  is  traversed  by  vessels  especially  by 
large  veins  and  arteries  frequently  presenting  a  tortuous  course; 
muscular  fibres  are  also  occasionally  seen  in  it.  The  third  layer,  the 
internal  envelope  of  the  wall  of  the  cyst,  has  a  serous  or  sero-mucous 
appearance,  is  lined  with  epithelial  cells  and  formed  by  the  internal 
membrane  of  the  Graafian  vesicle.  In  some  old  uni-locular,  multi- 
locular  or  mixed  cysts  the  envelope  is  encrusted  with  cartilaginous  or 
calcareous  matter  exactly  like  the  middle  coat  of  the  arteries  in  cases 
of  ossification.  The  contents  usually  consist  of  a  lemon  or  amber- 
coloured  serous  fluid  ;  but  they  vary  in  different  patients,  according  to 
the  size  of  the  cyst  and  according  to  the  period  at  which  the  fluid  is 
extracted,  the  number  of  punctures  which  have  been  made,  &c.  Thus 
the  fluid  is  sometimes  colourless,  viscous  and  albuminous,  or  rather  par- 
albuminous  (Koeberle),  coagulated  by  heat  and  nitric  acid,  being  pro- 
duced from  the  cavity  of  the  granular  membrane  (ovisac)  -^  sometimes 
it  is  very  thick,  containing  a  number  of  crystalline  lamellse  of  choles- 
terine,  or  a  variable  quantity  of  blood,  which  gives  it  a  chocolate 
colour  (hsemorrhagic  cysts,  lymphatic  cysts,  consecutive  to  the  fall  of 
the  capsule  and  of  its  rich  sanguineous  and  lymphatic  vascular  net- 
work); at  other  times  it  is  greenish  yellow  and  contains  a  considerable 
quantity  of  pus  which  denotes  inflammation  of  the  cyst  and  modifies 
the  prognosis. 

3.  Multiple  and  muUilocular  cysts.^ — These  are  the  most  nume- 
rous; only  it  must  be  observed  that  in  the  majority  of  cases 
one  of  the  divisions  is  developed  disproportionately  with  regard 
to  the  others,  and  that  although  the  latter  may  be  multiplied, 
they  remain  fixed  against  one  side  of  the  cyst,  usually  towards  the 

^  Kiwiscli  von  Eotterau  {Klinische  Vortrdge  ilher  specielle  Pathologie  und 
Therapie  der  Kranhheiten  des  weiblichen  Geschlechts.  Prague,  1849). — Paget 
{Surgical  Pathology,  vol.  ii,  p.  26). — Cruveilhier  {Anat.  pathol  gen.,  t.  iii, 
p.  398). 

'  The  microscope  reveals  the  existence  of  yellowish  gi-anular  globules 
of  .^-^^  mm.  in  diameter,  the  envelope  of  which  is  made  more  apparent  by 
acetic  acid,  the  granulations  not  being  dissolved  by  ether  (Bennet,  Koeberle, 
Drysdale). 

3  Farre  {Cyclopcedia  of  Anat.  and  Phys.;  Uterus  and  its  Appendages. 
London,  1859)  confines  the  term  muUilocular  to  cysts  in  which  partitions  have 
been  formed  in  consequence  of  endogenous  proliferation,  and  multiple  to  those 
formed  by  the  aggregation  of  several  simple  cysts,  developed  simultaneously  in 
the  same  ovary. 


OVARIAN  CYSTS  735 

pedicle  of  the  ovary,  a  circumstance  which,  from  a  clinical  point 
of  view,  reduces  all  cysts  of  this  category  to  the  condition  of  unilo- 
cular cysts.     In  other  cases  the  sacs  of  which  the  cyst  is  composed 


Fig.  403. — Eight  ovary  showing    numerous  unilocular  cysts,  consisting  pro- 
'  bably  of  dilated  Graafian  vesicles.     Left  ovary  similar,  unopened  (after 
Hooper). 

may  be  the  result  of  the  division  of  one  large  cyst  or  of  the  aggre- 
gation of  small  cysts  which  were  originally  independent  (these  are 
very  rare),  or  rather  as  the  result  of  endogenous  proliferation,  a  kind 
of  budding  of  the  internal  membrane,  giving  rise  to  smaller  or 
secondary  cysts,  from  which  are  developed  cysts  of  the  third  order. 


Fig.  404. — Left  ovary  distended  into  one  large  cyst,  in  the  interior  of  which 
numerous  smaller  cysts  of  the  second  order  project. 

The  various  divisions  rarely  communicate  with  each  other;  this 
peculiarity  is  only  manifested  in  cysts  divided  by  septa,  and 
there  is  then  always  a  good  number  of  sacs  which  remain  inde- 
pendent.     In    all  these  multilocular  cysts,  especially  in  those  re- 


736 


UTEEINE    DISEASES    IN    DETAIL 


suiting  from  an  aggregation  of  smaller  cysts  or  from  proliferation  of 
the  internal  membrane,  some  of  the  sacs  are  larger  than  others  ; 
generally  there  are  one  or  two  large  sacs,  a  larger  number  of  average 
size,  and  a  still  greater  number  quite  small,  from  the  size  of  a  millet- 
seed  to  that  of  a  nut.  The  septa  are  often  very  resistant,  and 
we  can  only  penetrate  from  one  into  another  by  successive 
punctures. 

The  contents  may  resemble  those  of  the  unilocular  cysts,  presenting 
the  same  differences  in  different  patients.  But  usually  they  are 
viscous,  gelatinous,  more  or  less  thick,  escaping  with  difficulty  by  the 
cannula  of  the  trocar,  especially  when  all  the  sacs  are  moderately  de- 
veloped and  nearly  equal,  and  sometimes  producing  no  precipitate 
with  heat  or  nitric  acid  (colloid  cysts,  cysto-adenomata,  adenoid 
tumours  of  the  ovaries).  But  what  proves  that  the  various  divisions 
are  independent,  and  gives  reason  to  presume  that  in  certain  cases 
this  independence  is  primary,  is  that  we  can  sometimes  see  that  the 
fluid  of  one  division  differs  more  or  less  in  nature,  consistency  and 
colour  from  that  of  another. 

3.  Mixed  or  composite  cysts. — They  are  characterised  by  the  addi- 
tion in  variable  proportions  to  the  cystic  products  of  new  pathological 
elements,  normal  or  abnormal,  simply  hypertrophic  or  the  result  of 
degeneration,  or  even  peculiar  to  the  ovary.     The  cyst  is  formed  not 


Fig.  405.— Compound  and  proliferant  Fig.  406.— Ovarian  cyst^  containing 
ovarian  cyst.  Secondary  and  ter-  hair,  fatty  matter,  adipose  tissue, 
tiary  cysts.  sebaceous  glands,  hair  follicles,  &c. 

(after  Cruveilhier). 


OVARIAN    CYSTS  737 

only  by  the  hypertrophied  envelope  of  the  ovisac  or  of  the  tissue 
proper  of  a  follicle,  but  also  by  the  hypertrophy  of  a  portion  of  the 
stroma  of  the  ovary  with  infiltration  of  serum  or  other  pathological 
fluids,  giving  to  the  envelope  at  one  or  several  points  an  abnormal 
thickness  and  a  peculiar  appearance  characterised  by  the  term  areolar  ; 
or  by  the  hypertrophy  of  the  fibrous  tissue,  forming  in  the  ovary  one 
or  several  fibroids  analogous  to  uterine  fibromata,  projecting  more 
or  less  into  the  cavity  of  the  cyst  and  encrusted  with  calcareous 
matter  at  one  or  several  points,  and  sometimes  attaining  to  so  con- 
siderable a  size  as  to  constitute  more  than  the  half  of  the  ovarian 
tumour  ;  or  by  the  formation  of  epithelial  cells,  multiplying  with  great 
rapidity  and  in  such  a  manner  as  to  make  them  resemble  other  tumours 
formed  by  the  proliferation  of  the  epithelial  cells  of  tubular  glands  and 
known  as  adenomata,  adenoid  tumours,  heteradenic  tumours ;  or  by  a 
matter  more  or  less  liquid,  more  or  less  solid,  presenting  in  its  structure, 
its  consistency,  its  external  form,  its  nodulated  appearance  and  its 
development  the  characters  of  colloid  matter,  scirrhus,  encephaloid, 
or  melanosis,  in  short  of  the  different  varieties  of  cancer. 

The  contents  of  one  division  may  differ  from  those  of  another, 
or  those  of  the  cavity  of  the  true  cysts  from  those  of  the  cystoids 
and  of  the  lacunse,  which  are  often  hollowed  out  in  the  pathological 
tissues  formed  around  them.  In  this  way  serum,  albuminous  fluids, 
sanguinolent  serosity,  pus,  epithelial  debris,  crystals  of  cholesterine, 
cancerous  fluid  are  sometimes  met  with  simultaneously  or  separately 
in  the  various  cavities  of  mixed  cysts. 

Dermoid  tissue  and  the  products  depending  on  it,  such  as  sebaceous 
or  fatty  matter,  tufts  of  hair,  bones,  teeth,  nails,^  &c.,  which  have 
been  falsely  attributed  to  ovarian  pregnancy,  are  products  which  may 
be  considered  as  partly  belonging  to  the  cyst  and  partly  to  its  con- 
tents. As  for  hydatid  cysts,  few  cases  are  recorded  of  their  develop- 
ment in  the  ovary  .^ 

Of  all  these  varieties  of  ovarian  cysts  which  is  the  one  which  most 
frequently  occurs  ?  The  only  statistics  which  we  have  are  those  of 
Scanzoni,  which  are  based  on  too  small  a  number  of  cases  to  allow  of 
the  question  being  determined.  But  the  following  interesting  remark 
made  by  Cruveilhier  shows  that  all  these  varieties  may  exist  in  a  rudi- 
mentary condition  in  ovaries  the  size  of  which  is  hardly  increased. 
"  The  ovaries  may  present  in  miniature  all  the  varieties  of  large 
ovarian  cysts.  For  instance,  we  find  in  these  little  ovaries,  hardly  as 
large  as  a  pigeon''s  egg,  serous  unilocular  cysts,  serous  multilocular 
cysts,  multiple  cysts,  areolar  cysts,  the  whole  being  in  infinitely  small 
proportions  but  remarkably  clear ;  they  are  perhaps  cysts  in  the  first 
stage  which  abort  for  want  of  nutrition.^'^ 

1  Cruveilhier  {Anat.  path,  gen.,  t.  iii,  p.  572).  Accoiding  to  Kocberl^  der- 
moid cysts  are  more  frequently  to  the  right.  Patients  affected  by  them  usually 
enjoy  good  health. 

*  Bauchet,  Anat.  path,  des  Icystes  de  I'ovaire,  &c.  {Mem.  de  I' Acad,  de  med., 
t.  xxiii,  p.  49.  Paris,  1859). — Charcot,  Mem.  sur  les  tumeurs  hydatiques,  &c. 
{Gaz,  med.,  1852). —  Davaine,  Traite  des  entozoaires. 

^  Cruveilhier,  Anat.  path,  gen.,  iii,  p.  445.  Paris,  1856, 

47 


738  UTEEINE    DISEASES    IN    DETAIL 

The  origin  and  development  of  these  various  kinds  of  cysts  are 
hardly  doubtful.  Exceptionally  they  are  external  to  the  ovary ;  but 
the  development  of  considerable  cysts  formed  at  the  expense  of  Eosen- 
miiller's  organ,  the  remains  of  the  Wolffian  body,  or  at  some  point  of 
the  broad  ligaments  is  a  fact  which,  although  verified,  is  very  rare.^ 
In  the  immense  majority  of  cases  it  cannot  be  denied  that  it  is  the 
ovary  which  is  the  seat  of  development  of  ovarian  cysts.  Neither  can 
it  be  denied  that  the  tissue,  improperly  called  stroma,  of  this  organ  is 
usually  foreign  to  their  formation,  and  that  it  is  equally  difficult  to 
trace  their  origin  to  vesicles  said  to  be  formed  any  how  or  first  coming 
to  light  in  the  interstices  of  this  stroma.  Both  indirectly  by  the 
method  of  exclusion  and  by  direct  observation  we  are  led  to  seek  the 
origin  of  these  cysts  in  the  development  of  the  ovisacs  or  Graafian 
vesicles  (which  Cazeaux  called  ovarian  cysts  in  miniature  2),  and  to  verify 
the  alterations  of  nature  and  direction  which  vitiate  this  development,^ 
rendering  it  pathological  and  deviating  it  from  its  destination  of  the 
ovigenous  capsule  to  the  monstrous  development  of  a  more  or  less 
complex  cyst.  In  short,  these  cysts  are  simple  or  complex  dropsies  of 
Graafian  vesicles  (follicular  dropsy). 

It  is  not  rare,  especially  in  pregnant  or  puerperal  women,  for  a 
number  of  follicles  to  become  dropsical  and  for  ovules  to  be  found 
when  the  fluid  which  is  obtained  in  opening  each  separately  is  care- 
fully preserved ;  conditions  of  this  kind  usually  coincide  with  catarrhal 
leucorrhceic  affections  of  the  genital  economy ;  they  may  simulate 
menstruation,  being  accompanied  by  a  sanguineous  discharge  (pseudo- 
menstruation),  and  merit  the  name  of  catarrh  of  the  Graafian  follicles.* 

Not  only  do  Cruveilhier/  Eokitansky,^  Lebert,'''  and  the  majority  of 
pathological  anatomists  admit  this  origin,  at  least  for  simple  unilocular 
or  multilocular  cysts,  but  Wilson  Eox^  has  described  the  manner  in 
which  the  increase,  proliferation,  and  endogenous  multiplication  of  the 
internal  membrane  of  the  vesicle  are  produced  in  the  formation  of  a 
multilocular  cyst.  The  excrescences  which  arise  from  the  internal 
wall  of  these  cysts  and  which  have  obtained  for  them  the  name  of 
proliferous    cysts,    are    papillary    fibroid    excrescences,    dendritic    or 

^  Bauchet,  op.  cit.,  p.  54. — Rafael  Herrera  Vegas,  i^tudes  sur  les  Jcystes  de 
I'ovaire  et  l' ovariotomie,  p.  16,  note  by  Oi'donez.  These  de  Paris,  1864. — ■ 
Spencer  "Wells,  Diseases  of  the  Ovaries,  i,  pp.  91,  240,  303.  London,  1865.  See 
further  on  the  origin  of  cysts  of  the  broad  ligament  (p.  781). 
•  '^  Des  kystes  de  I'ovaire,  these  pour  I'agregation.  Paris,  1844  (a  remarkable 
work). — Bulletin  de  I' Acad,  de  med.  de  Paris,  1856. 

^  Hsemorrhage  into  an  ovisac  appears  sometimes  to  be  the  origin  of  this 
pathological  development,  as  several  preparations  in  Guy's  Hospital  seem  to 
prove  (Bright,  Guy's  Hospital  Beports,  vol.  iii,  pp.  181  and  193.  London,  1831). 

*  Virchow,  op.  cit.,  t.  i,  p.  259. 

•''  Anat.  path,  gen.,  iii,  395.  Paris,  1856. 

®  Lehrbuch  der  patholog.  Anat.,  iii,  424.  Vienna,  1861. —  Wiener  Wochen- 
blatt,  1855,  No.  1,  and  Abnormitaten  des  Corp.  luteum,  in  Wiener  allg. 
med.  Zeitung,  1859,  pp.  34  and  35. 

''  Physiologic  pathologique,  ii,  p.  65.  Paris,  1845. — Anatomie  pathologique. 
Paris,  1855—61. 

*  On  the  Origin,  Structure  and  Mode  of  Development  of  the  Cystic  Tumours 
of  the  Ovary  {Medico-Chirurg .  Transactions,  xlvii,  p.  227.  London,  1804). 


OVAEIAN    CYSTS 


739 


cauliflower^  villous  or  vascular,  or  it  may  be  glandular,  formed  by  the  jux- 
taposition of  these  latter ;  they  are  probably  multiplied  by  the  same  patho- 
logical process  which  leads  to  the  formation  of  vesicular  moles,  i.e. 
which  produces  multiplication,  hypertrophy^  and  dropsy  of  the  chorial 
villi.  The  fusion  in  places  of 
these  excrescences  and  their 
ulterior  development,  the  divi- 
sion by  septa  of  glands  of  new 
formation,  the  elongation  and 
division  of  the  numerous  micro- 
scopic cysts  contained  in  the 
wall,  account  sufficiently  for 
the  development  of  the  sacs, 
which  are  often  so  numerous 
and  of  such  different  dimen- 
sions, in  ovarian  cysts. 

Diagnosis  —  subjective  signs. 
— Ovarian  cysts,  like  all  ute- 
rine maladies,  are  usually  pro- 
duced during  the  age  of  sexual 
activity,^  but  they  may  be  met 
with  in  childhood^  (I  have  seen 
one  in  a  child  of  'eleven  who  had 
never  menstruated),  and  may  also 
be  developed  in  old  age ;  in  the 
latter  case  they  are  very  seldom 
fully  developed  but  appear  as  if 
atrophied.  When  they  have 
commenced  during  the  period 
of  sexual  activity  without  deter- 
mining serious  accidents  they  may  continue  to  develop  after  the 
menopause  and  become  enormous  even  in  women  of  60.  Ovarian 
•cysts  are  met  with  in  virgins  and  widows  as  well  as  in  married 
women,^  which  shows  the  slight  influence  exercised  by  coitus  on  their 
development.  They  also  occur  in  women  who  have  never  con- 
ceived,* and  so  frequently  that  we  may  conclude  that  probably  the 

^  The  frequency  of  ovarian  tumours  with  regard  to  age  is  as  follows  : 
According  to  Chereau,  out  of  230  there  are  133  between  17  and  37  years  of  age. 
Lee,  „       135        „  82        „       20    „   40 

„  Scanzoni,    „         97         „  70         „        18    „    40  „ 

West,  „         94        „  64        „       25    „    40 

^  And  even  in  the  newborn  infant.     See  Boullard  and  Mayer  of  Bonn,  quoted 
by  Bauchet,  op.   cit.,   p.  7. — Cullingworth,  quoted   by  Hayem,  Revue,  t.  v, 
p.  762. — Kiwisch,  op.  cit.,  ii,  p.  79. 
^  There  were  according  to 

Lee,  out  of  136  patients,  88  married  women,  37  virgins,  11  widows. 
Scanzoni,  „    97         ,,         45  ,,  4f)        „         1         ,, 

West,        „    94        „        57  „  24        „       13 

Tilt,  _       „  475        „      289  „  166        „      20 

''  According  to  Scanzoni,  out  of  97  patients  51  were  n\illipara3  (out  of  the 
51  there  were  16  virgins).  According  to  West,  out  of  70  married  women  or 
widows  26  were  nulliparae. 


Fig.  407. — Part  of  the  wall  of  an  ovarian 
cyst,  covered  on  the  internal  surface 
with  cauliflower  excrescences  and  py- 
riform  vesicles  (after  Paget). 


740 


UTERINE    DISEASES    IN    DETAIL 


Fig.  408.  —  Follicular 
dropsy  of  the  ovary 
in  a  cliild  of  ten 
(Vircliow) . 


ovaries  were  (before  the  apparent  development  of  the  tumour)  in  a 
pathological  state  incompatible  with  the  normal  accomplishment  of 
their  functions.  They  may  be  developed  in  either  ovary,  but  more 
frequently  in  the  right,  at  least  in  the  case  of 
dermoid  cysts  (according  to  Koeberle  albumi- 
nous cysts  are  more  frequently  situated  on  the 
left  side),  and  in  a  number  of  cases  in  both 
ovaries  simultaneously.  Tilt^  has  observed  out 
of  475  cases  of  ovarian  cysts  that  the  seat  of 
the  malady  was  in  the  right  ovary  260  times,  in 
the  left  170  times,  and  in  both  ovaries  43  times. 
These  statistics,  as  well  as  those  of  Lee,  Che- 
reau,  Scanzoni  and  West,^  seem  to  confirm 
the  relative  frequency  of  the  development  of 
cysts  in  the  right  ovary  ;  but  it  is  only  based, 
like  the  others,  on  the  rather  uncertain  data  of 
a  diagnosis  made  during  life.  The  post-mortem 
examination  of  80  cases  recorded  by  Scanzoni,  Lee,  and  West  does 
not  exactly  confirm  this  result ;  for  in  these  80  cases  the  malady 
only  occupied  the  right  side  28  times,  the  left  26  times,  and  both 
ovaries  26  times.  Sometimes  they  are  developed  without  the  slightest 
disturbance  of.  the  neighbouring  organs  and  general  economy,  or 
they  produce  only  a  sensation  of  discomfort  j  after  a  time,  however, 
they  increase  rapidly.  At  other  times  symptoms  are  manifested  in 
the  pelvis,  such  as  a  sensation  of  weight,  rectal  or  vesical  tenesmus, 
retention  of  urine,  menstrual  and  other  functional  disturbances.  If 
the  tumour  is  formed  rapidly  or  accompanied  by  irritation  or  inflam- 
matory phenomena,  the  commencement  even  may  be  marked  by 
shooting  pains  in  the  diseased  ovary.  In  some  women  pain  is  never 
felt  at  all,  whilst  in  others  on  the  contrary  it  is  produced  in  proportion 
to  the  rapid  development  of  the  cyst,  to  the  congestion  caused  by  the 
catamenial  fluxion  in  the  diseased  ovary,  to  the  development  of  inflam- 
mation in  it,  or  to  the  degree  of  inflammation  set  up  in  the  peritoneal 
serous  membrane  by  which  adhesions  are  formed  between  the  cystic 
envelope  and  the  visceral  or  parietal  peritoneum,  which  by  interfering 
with  the  mobility  of  the  cyst  produce  additional  pain.  At  an  advanced 
period  pain  is  also  produced  by  the  compression  which  the  cyst  exer- 
cises on  the  neighbouring  organs — the  bladder,  rectum,  intestine, 
stomach,  ureters,  sciatic  nerve,  &c. —  and  by  the  difficulties  which  it 
places  in  the  way  of  their  functions. 

The  increase  in  the  size  of  the  cyst  is  not  continuous ;  sometimes 
the  tumour  remains  stationary  for  a  long  time,  and  then  suddenly 
makes  great  progress,  which  only  ceases  when  the  ovarian  sac  and  ab- 

1  The  Lancet,  Dec,  1849,  Feb.,  March,  1850. 

^  The  seat  of  ovarian  tumours  is  according  to 

Chereau,  out  of  215  cases,  109  to  the  right,  78  to  the  left,  28  on  both  sides. 

Lee,       _      „         93      „        50           „            35  „  8 

Scanzoni,     „         41      „        14           „            13  ,,  14            „ 

West,           „         92      „        35           „            38  „  19 

BlofE,          „        54     „       31           „            23  „  0 


OVARIAN    CYSTS  741 

domiual  cavity  are  distended  to  their  utmost  limits.  At  other  times 
the  increase  of  the  tumour  is  intermittent,  the  fits  of  development 
often  corresponding  with  the  menstrual  period.  The  compression  of 
neighbouring  organs,  whether  in  the  pelvic  or  abdominal  cavity,  gives 
rise  to  new  symptoms.  The  bladder  being  at  first  compressed  on  a 
level  with  the  cervix,  and  afterwards  pushed  against  the  pubis,  or 
raised  upwards  towards  the  abdomen,  there  is  at  one  time  dysuria, 
vesical  tenesmus  and  retention,  and  at  another  incontinence  of  urine. 
If  the  ureters  themselves  are  compressed  the  catheter  is  powerless,  and 
the  urine  accumulates  in  these  excretory  canals  which  become  enor- 
mously distended.  Compression  of  the  intestines  often  causes  con- 
stipation and  occasionally  alternations  of  constipation  and  diarrhoea; 
but  I  have  seen  many  patients  in  whom  the  bowels  acted  regularly 
owing  to  the  fact  that  the  sigmoid  flexure  and  rectum  experienced  but 
slight  compression  from  the  tumour,  as  it  had  risen  into  the  abdomen ; 
on  the  other  hand  compression  may  be  strong  enough  to  determine 
intestinal  occlusion^  and  stricture  of  the  rectum.  Compression  of 
the  intra-abdominal  vessels  causes  dilatation  of  the  superficial  ab- 
dominal veins,  which  form  blue  networks  under  the  skin  to  take  the 
place  of  the  deep  venous  circulation,  oedema  of  the  vulva,  especially 
of  the  lahla  majora,  more  rarely  oedema  of  the  lower  limbs  and  ab- 
dominal walls  and,  more  rarely  still,  ascites.  Pressure  on  the  sciatic 
nerve  determines  a  pricking  sensation,  pulsating,  darting  pains  shooting 
down  the  thigh  of  the  diseased  side.  The  phenomena  of  compression 
of  the  pelvic  organs  are  manifested  especially  at  the  beginning,  when 
the  cyst  is  contained  in  the  pelvis  ;  in  proportion  as  it  rises  and  as 
the  utero-ovarian  pedicle  is  elongated,  these  phenomena  disappear,  and 
it  is  on  this  account  that  we  often  see  the  lower  limbs  emaciated  and 
wrinkled,  and  forming  a  singular  contrast  with  the  enormous  disten- 
sion of  the  belly.  1  have  even  seen  cases  in  which  the  excavated 
form  of  the  tumour  behind  (owing  to  a  movement  of  torsion  effected 
by  the  ovary  in  the  first  period  of  the  development  of  the  tumour) 
allowed  the  large  vessels  in  the  abdomen  to  escape  all  pressure. 
Lastly,  at  the  most  advanced  period  the  effect  of  the  compression 
exercised  by  the  cyst  is  felt  especially  by  the  thoracic  organs,  disturb- 
ing respiration  and  the  cardiac  circulation. 

Menstruation  is  variable.  In  some  patients  the  appearance  of  the 
tumour  is  preceded  by  menstrual  disorders  (according  to  Scanzoni, 
37  times  out  of  57);  after  the  cyst  is  developed  it  may  seem  to  exer- 
cise no  influence  on  the  regularity  of  the  monthly  period,  especially 
if  one  ovary  remains  normal ;  it  sometimes  is  accompanied  by  metror- 
rhagia, more  frequently  by  dysmenorrhoea  or  amenorrhoca ;  the  per- 
sistence of  the  cystic  tumour  does  not  prevent  the  menopause  from 
being  established  normally  ;  the  definite  increase  of  the  cyst  and  the 
cessation  of  the  catamenia  seem  in  a  few  patients  to  be  two  concurrent 
phenomena.  When  the  menses  cease  completely  from  the  commence- 
ment of  the  malady  we  may  suppose  that  there  is  some  serious  disorder, 
i.  e.  a  cancerous  or  other  degeneration  of  the  tissue  of  both  ovaries ; 
'  Cniveilhier,  Anat.  ludh.  g<hi.,  iii,  p.  412. 


742 


UTEEINB    DISEASES    IN    DETAIL 


for  the  menses  continue  even  with  cysts  in  the  two  ovaries  if  any 
portion  of  the  organs  preserves  its  normal  structure  and  is  able  to 
perform  its  functions.  It  is  impossible  for  so  large  a  tumour  to  distend 
the  abdominal  cavity  without  the  general  health  suffering  greatly ; 
therefore,  although  some  patients  only  succumb  after  repeated  punc- 
tures, and  after  carrying  the  tumour  for  more  than  twenty  years,  there 
are  others  in  whom  the  cyst  reaches  an  enormous  size  in  six  months, 
weighing  55  lbs.,  and  rapidly  ending  fatally.     The  average  duration 


Fig.  409. — "  Facies  ovariana,"  from 
the  photograph  of  a  patient  of 
42  who  had  a  compound  ovarian 
cyst,  operated  on  and  cured  by 
Spencer  Wells. 


Fig.  410. — External  aspect  of  the  ab- 
dominal tumour  formed  by  a 
multilocular  ovarian  cyst  in  a 
woman  of  32  (ovariotomy,  cure, 
birth  of  a  child  15  months  after- 
wards).    (After  Spencer  Wells.) 


of  life  is  from  two  to  three  years.  The  tumour  injures  the  con- 
stitution in  three  ways  ;  by  the  mechanical  obstacle  it  opposes  to 
the  movements  of  the  organs,  to  their  circulation  and  to  the  accom- 
plishment of  their  functions  ;  by  the  irritation  or  sympathetic  dis- 
orders which  it  occasions  in  others ;  lastly,  by  the  change  of  direc- 
tion given  to  nutrition,  the  growth  of  the  cyst  and  the  increase  in  its 
secretion  taking  place  at  the  expense  of  the  general  assimilation 
throughout  the  system. 

The  alteration  in  the  general  health  is  especially  noticeable  in  young 
women  and  when  the  tumour  is  rapidly  developed.  Without  speaking 
of  such  complications  as  inflammation  of  the  cyst,  secretion  of  pus. 


OVARIAN    CYSTS  743 

&c.,  which  greatly  accelerate  the  course  of  the  disease,  we  may  say 
that  in  such  cases  digestion  is  difficult  and  slow,  the  intestines  swell, 
respiration  is  impeded,  especially  after  meals ;  circulation  is  not  per- 
ceptibly affected,  there  is  little  or  no  fever,  but  the  difficulty  which  the 
blood  has  in  circulating  through  the  large  vessels  causes  a  small  and 
frequent  pulse,  palpitations  and  a  tendency  to  syncope.  Under  the  in- 
fluence of  these  disorders  of  the  principal  functions,  of  their  reaction 
on  the  nervous  system,  of  the  anaemia  which  results,  and  of  the 
attraction  exercised  by  the  cyst  on  the  elements  of  nutrition,  increasing 
emaciation  is  produced.  The  lower  extremities  when  not  oedematous 
acquire  a  dryness  and  spareness  contrasting  with  the  infiltration  to 
which  they  are  subject  in  the  case  of  ascites  ;  the  hands  and  arms 
become  thin;  the  chest  and  neck  contrast  by  the  angular  projection 
of  their  bones  with  the  spheroidal  tumefaction  of  the  upper  portion 
of  the  abdomen ;  the  face,  too,  is  affected  by  this  general  emaciation ; 
it  becomes  wrinkled,  the  lips  are  pinched,  the  nose  pointed,  the  eyes 
sunk,  all  the  features  acquiring  the  look  of  premature  old  age, 
although  the  still  briUiant  eye  shows  that  vitality  is  stifled  by  the  de- 
velopment of  a  parasite  rather  than  disorganised  in  its  constituent 
elements.  This  appearance  differs  considerably  from  that  which 
cancer,  chlorosis,  chloro-ansemia,  and  even  recent  delivery  and  uterine 
diseases  impart  to  the  countenance,  so  much  so  that  Spencer  Wells 
has  designated  it  by  the  name  of  ''  facies  ovariana"  to  contrast  it  with 
the  "  facies  uterina  "  which  I  have  already  described. 

Objective  signs. — Palpation  must  be  combined  with  vaginal  and 
rectal  touch  in  order  at  the  beginning  to  be  able  to  diagnose  in  the 
pelvis  the  presence  of  a  tumour  which  is  often  indolent,  varying  in 
size  from  that  of  a  nut  to  that  of  a  fretal  head,  round,  resistant,  but 
depressible  and  elastic,  or  soft  and  fluctuating,  escaping  from  the  grasp 
of  the  fingers,  mobile  in  several  directions,  pushing  the  uterus  for- 
wards or  on  one  side,  and  compressing  the  rectum  more  or  less. 
When  the  cyst  is  situated  above  the  brim  it  increases  the  size  of  the 
belly.  This  symptom  seems  to  strike  the  patient  less  than  the  phy- 
sician, when  the  tumour  is  indolent;  but  the  increased  size  of  the 
abdomen  as  ascertained  by  measurement,  the  form  of  the  tumour,  the 
results  furnished  by  palpation,  percussion  and  touch,  leave  no  doubt 
as  to  the  origin  and  nature  of  the  malady.  The  abdomen  is  not  only 
tumefied  but  altered  in  its  form.  In  place  of  being  distended  in  every 
direction  as  by  ascites  it  is  manifestly  raised  by  a  globular  tumour, 
recalling  that  of  the  gravid  uterus,  but  sometimes  nodulated  instead 
of  simple,  less  central,  less  inchned  to  the  right,  commencing  usually 
on  one  side  and  directed  towards  the  hypogastrium,  making  the 
abdomen  project  in  its  median  portion  where  it  yields  more  than 
elsewhere,  and  rising  towards  the  epigastrium  or  hypocliondrium. 
Ovarian  cysts  may  acquire  an  enormous  size,  filling  the  whole  belly 
and  distending  the  envelopes  and  skin  excessively,  producing  streaks 
and  vibices  and  describing  broad  blue  undulating  lines  due  to  the  dis- 
tension of  the  subcutaneous  veins,  descending  in  front  of  the  thighs  to 
the  knees  and  pushing  the  false  ribs  and  xiphoid  cartilage  of  the 


744  UTEEINE    DISEASES    IN    DETAIL 

sternum  upwards  and  outwards,  weighing  as  much  or  even  more  than 
the  patient  herself.  I  have  seen  some  which  measured  more  than  two 
yards  in  circumference,  and  from  which  I  extracted  thirty  quarts  of 
fluid.^  The  density  of  this  fluid  being  greater  than  that  of  water  and 
the  weight  of  the  cystic  envelope  and  of  the  tumours  adhering  to  it 
varying  from  eleven  to  thirty-three  pounds,  we  can  judge  of  the 
enormous  weight  which  the  presence  of  such  a  tumour  adds  to  that  of 
the  patient,  which  emaciation  sometimes  reduces  below  110  pounds. 
The  weight  of  the  tumour  has  been  known  to  exceed  165  pounds 
(Kimball). 

Palpation  discovers  the  size  and  limits  of  a  round  tumour,  occasion- 
ally nodulated,  regularly  circumscribed,  usually  indolent;  sometimes 
mobile,  being  easily  displaced  under  the  combined  influence  of  palpa- 
tion and  change  of  posture,  falling  to  the  most  dependent  side ;  some- 
times retained  in  one  of  the  iliac  fossse  or  towards  the  upper  portion 
of  the  abdomen ;  usually  tense,  seldom  depressible  or  soft ;  however 
mobile,  fixed  in  the  pelvis  by  a  more  or  less  loose  pedicle ;  difficult  to 
circumscribe  and  still  more  so  to  move  when  it  completely  fills  the 
abdominal  cavity  and  distends  the  cutaneous  envelope  excessively. 
Palpation  often  enables  us  to  verify  the  simultaneous  presence  of  solid 
tumours  and  of  an  encysted  fluid  by  the  difference  in  consistency, 
hardness,  or  resistance.  On  percussion  dulness  is  perceived  through- 
out the  whole  extent  of  the  tumour,  at  its  summit,  at  the  apex  of  the 
belly  if  the  patient  is  lying,  as  well  as  near  the  pubis  and  iliac  fossae. 
There  is  tympanitic  resonance  in  the  posterior  portions,  in  the  flanks, 
towards  the  loins,  in  the  epigastrium  and  in  the  hypochondriac 
regions,  especially  on  the  left  side.  The  dulness  does  not  change  per- 
ceptibly on  the  patient  changing  her  position.  Fluctuation  should  be 
carefully  sought  for.  It  is  well  marked  when  the  cyst  is  large,  serous 
and  unilocular ;  in  other  cases  it  is  obscure  and  may  even  be  absent. 
Sometimes  in  trying  to  discover  fluctuation  the  displacement  en  masse 
of  the  contents  of  the  cyst  is  perceived,  pushed  back  by  one  hand 
of  the  examiner  towards  the  other ;  but  what  Cruveilhier  calls  the 
choc  par  contre-cou'p  is  not  perceived ;  that  is  when  the  contained 
matter  is  soft  rather  than  fluid  or  when  there  are  several  contiguous 
cysts.  At  other  times  we  perceive  very  distinctly  this  choc  par  contre- 
coup,  i.e.  the  result  of  the  molecular  disturbance  produced  by  very 
rapid  percussion  suddenly  imprinted  on  the  point  diametrically  oppo- 
site that  on  which  the  hand  is  placed  ;  but  this  shock  can  only  be  felt 
at  short  distances,  the  undulation  is  shut  off  (multilocular  cysts),  or  it 
is  perceived  from  one  pole  of  the  tumour  to  the  other  (unilocular 
cysts)  ;  sometimes  a  multilocular  cyst  with  one  large  predominating 
cyst  is  diagnosed  in  this  way. 

Yaginal  touch  (which  when  necessary  should  be  followed  by  rectal 
touch),  either  alone  or  combined  with  palpation  and  percussion, 
enables  us  to  diagnose  deviations  and  even  displacements  of  the  uterus, 

^  I  have  recently  extracted  nearly  50  qitarts  from  an  enormous  cyst,  which 
I  have  reason  to  suppose  was  developed  from  the  broad  ligament,  for  the 
transparent,  serous,  slightly  yellowish  fluid  did  not  coagulate  on  boiling. 


OVAEIAN    CYSTS  745 

sometimes  ascent,  sometimes  prolapsus,  at  other  times  compression 
towards  the  pubic  symphysis  and  auteversion,  more  frequently  a  lateral 
or  posterior  inclination/  and  a  certain  degree  of  torsion.  It  is  impor- 
tant to  determine  at  the  same  time  whether  the  uterus  is  mobile;  this 
mobility  depends  on  the  variable  length  of  the  pedicle  of  the  ovarian 
tumour  formed  by  the  Fallopian  tube  and  the  peritoneal  fold  enclosing 
the  ovarian  vessels  and  nerves.     Vaginal  touch  also  reveals  the  pre- 


FiG.  411. — External  aspect  of  the  abdominal  tumour  formed  by  a  compound 
ovarian  cyst  in  a  woman  of  34,  complicated  with  ascites,  dilatation  of  the 
subcutaneous  veins,  impossibility  of  sleeping  except  in  a  chair,  &c.  (ovari- 
otomy and  death  the  fifth  day).     After  Spencer  Wells. 

sence  of  the  cyst  in  the  pelvic  cavity  when  the  tumour  is  as  yet  but 
slightly  developed,  or  when  it  presents  prolongations  and  inequalities 
on  its  lower  portion.  In  other  cases  it  hardly  allows  of  our  reaching 
the  cyst,  or  only  when  pressure  of  the  other  hand  on  the  abdomen 
pushes  down  the  cyst  and  enables  the  tip  of  the  finger  to  perceive  its 
rounded  surface,  and  to  recognise  its  resistance,  depressibility  and 
fluctuation.  It  also  enables  us  to  form  an  opinion  as  to  whether  the 
cyst  is  in  the  right  or  left  ovary,  according  to  whether  the  uterus 
inclines  to  right  or  left.  The  sound  will  help  us  to  judge  of  the 
mobility  of  the  uterus,  of  the  length  of  the  pedicle,  of  the  presence  or 
absence  of  adhesions  between  the  cyst  and  the  uterus,  &c. 

Auscultation  furnishes  valuable  indications  as  to  the  presence  of 
vessels  in  the  pedicle  or  in  the  broad  ligament  in  front  of  the  tumour 
in  consequence  of  torsion,  enabling  us  to  avoid  wounding  them  by 
puncture.  It  also  enables  us  to  perceive  the  vibrations  resulting  from 
friction  of  the  tumour  against  the  parietal  peritoneum  due  to  the 
absence  of  adhesions,  whilst  in  other  cases  it  allows  us  to  hear  a 
rougher  and  more  or  less  extensive  friction,  coinciding  with  a  tliril. 
(falsely  attributed  to  hydatids)  caused  by  inequalities  produced  on  the 

''  According  to  Buinet,  (lie  cervix  is  always  pushed  to  tlie  opposite  side  from 
the  cvst. 


746  UTEEINB    DISEASES    IN    DETAIL 

serous  membrane  by  an  inflammation  which  has  only  developed  partial 
adhesions  more  or  less  distant  from  each  other. 
Differential  diagnosis : 

1.  Other  tumours  which  may  be  confounded  with  ovarian  cysts. — 
1.  Amongst  pelvic  tumours  parovarian  cysts  of  the  broad  ligament 
are  developed  more  slowly,  are  smaller,  are  hardly  ever  adherent,  may 
be  enucleated  from  the  peritoneum,  the  two  folds  of  which  cover  them 
and  contain  a  limpid,  slightly  salt  but  never  paralbuminous  fluid,  and 
never  emaciate  the  patient  so  much  as  ovarian  cysts.  However,  they 
also  may  become  very  voluminous,  giving  rise  to  errors  of  diagnosis.^ 
Peritoneal  and  subperitoneal  serous  cysts  analogous  to  the  preceding, 
with  walls  constituted  by  false  membranes  or  a  kind  of  ectasia  of  the 
lymphatic  vessels,  seldom  attain  a  considerable  size,  contain  albumen 
but  not  paralbumen  and  have  sometimes  a  pediculated  form.^  As  for 
other  pelvic  tumours  I  have  described  them  sufliciently  when  treating 
of  ovaritis,  tumefaction  and  inflammation  of  the  tubes,  dropsy  of  these 
organs,  anteflexion,  retroflexion,  extra-uterine  pregnancy,  uterine 
tumours,  especially  fibromata,  commencing  pregnancy,  hematocele,  &c., 
to  make  it  unnecessary  to  distinguish  them  here  from  ovarian  cysts. 

2.  Amongst  abdominal  turnours  ascites  is  easily  distinguished  by 
the  uniform  distension  of  the  belly,  the  absence  of  any  tumour  percep- 
tible to  palpation,  the  marked  tympanitic  note  at  the  summit  of  the 
abdomen  with  dulness  in  the  dependent  parts,  the  displacement  of  the 
resonance  and  dulness  agreeing  with  change  of  position  of  the  trunk, 
pelvis  and  abdominal  cavity,  the  frequent  oedema  of  the  lower  limbs  or 
real  anasarca,  &c.  Serous,  purulent,  or  hydatid  cysts  or  solid  tumours 
of  the  abdominal  walls,  of  the  peritoneum,  epiploon,  mesentery,  liver, 
spleen  or  kidneys  are  usually  distinguished  by  the  origin  of  the 
tumour,  its  initial  seat  above,  in  front,  to  right  or  to  left,  its  develop- 
ment from  above  downwards,  from  one  side  to  the  other  or  from  before 
backwards,  instead  of  from  below  upwards,  the  possibility  of  limiting 
the  tumour  beiieath  with  the  hand  and  of  defining  its  lower  outline, 
the  absence  of  any  pedicle  or  pelvic  adhesions^  verified  by  raising  the 
pelvis  and  lowering  the  shoulders  so  as  to  make  the  abdominal  organs 
weigh  on  the  diaphragm  and  not  on  the  pelvis,  the  independence  of  the 
uterus  with  regard  to  these  tumours,  an  independence  verified  by  digi- 
tal touch,  and  lastly,  by  the  local  or  general  symptoms  manifested  in 
the  organ  in  which  the  abdominal  tumour  is  developed.  Nevertheless 
there  are  tumours  the  diagnosis  of  which  is  very  difficult,  all  the  more 
so  that  fluctuating  tumours,  encysted  peritonitis,^  cysts  analogous  to 

^  Arning  of  Hamburg  successfully  operated  upon  an  enormous  cyst  of  the 
broad  ligament,  taken  by  Spencer  Wells  himself  for  an  ovarian  cyst  {Annales 
Gynecol.,  1877). 

^  Kojberle  {Gaz.  med.  cle  Strasbourg,  1876,  No.  1). 

^  Puistienne,  Remarques  et  observations  sur  qiielques  tumeurs  enhystees 
pelviennes  ou  abdominales  cliez  la  femvie,  p.  82.  Paris,  1867. — Kuackenbusch 
of  Albany  (the  Medical  Record,  Feb  ,  1875. — Annales  de  Gynecologic,  vi., 
237)  relates  two  cases  of  sub-peritoneal  cystic  tumours  which  were  taken  for 
cysts  of  the  ovary. 


OVARIAN   CYSTS  747 

areolar  gelatiniform  cysts  of  the  ovary/  and  hydatid  cysts/  may 
originate  in  the  subperitoneal  cellular  tissue  intermediate  between  the 
uterus  and  bladder,  or  retro-uterine  or  even  in  the  broad  ligament. 
Such  tumours  of  the  epiploon^  have  been  taken  for  ovarian  cysts. 
When  the  tumour  is  a  hydatid  cyst  enclosing  echinococci,  more  fre- 
quent in  the  liver,  spleen,  kidneys  and  epiploon  than  in  the  other 
abdominal  organs,  the  thrill  which  is  said  to  be  pathognomonic  can 
be  felt  by  palpation.  Pibrous  or  fibro-cystic  tumours  of  the  womb, 
all  the  more  difficult  to  diagnose  that  they  may  be  complicated  with 
ovarian  cysts,  are  distinguished  by  the  countenance  of  the  patient 
which  is  usually  normal,  and  by  the  uniformly  hard  or  flabby  consis- 
tency of  the  tumour.  I  do  not  speak  of  advanced  extra-uterine  preg- 
nancy nor  of  advanced  normal  pregnancy  characterised  by  the  signs  of 
gestation,  nor  of  retention  of  urine  nor  of  the  accumulation  of  fsecal 
matters  which  are  easily  recognised. 

II.  The  different  varieties  of  cysts  and  other  ovarian  tiimours. — 
Multilocular  cysts  are  sometimes  distinguished  from  unilocular  cysts 
by  the  appearance  of  several  globular  or  spheroidal  projections;  more 
frequently  by  the  impossibility  of  perceiving  fluctuation  except  by 
placing  the  hands  at  a  short  distance  from  each  other,  or  of  emptying 
the  cyst  by  an  exploratory  puncture  unless  the  several  divisions  can 
be  punctured  successively  by  inclining  the  trocar  in  different  directions 
after  the  contents  of  the  first  sac  have  been  evacuated ;  even  then  we 
frequently  only  succeed  in  withdrawing  small  quantities  of  fluid  and  in 
slightly  diminishing  the  size  of  the  tumour.  We  can  also  ascertain 
the  nature  of  the  fluid  which  is  more  gelatinous  and  thicker  in  multi- 
locular cysts,  or  which  may  differ  in  one  secondary  cyst  from  another. 

Compound  cysts  may  be  recognised  by  the  presence  of  hard,  resistant, 
non-elastic,  non-fluctuating,  solid  portions,  having  a  dulness  more 
marked  at  some  point  of  the  periphery  of  the  cyst,  either  at  its  upper 
portion  and  sides  or  at  its  lower  portion.  Diagnosis  becomes  easier 
"when  the  exploratory  puncture  has  evacuated  a  part  or  the  whole  of 
the  fluid  contained  in  the  cyst. 

Like  other  ovarian  tumours,  cysts  may  be  developed  either  to  the 
right  or  left ;  we  can  easily  ascertain  this  when  the  cyst  is  only  slightly 
developed,  and  we  may  suspect  it  in  other  cases  from  various  indica- 
tions given  by  the  patient.  In  rarer  cases  they  are  simultaneously 
developed  on  both  sides.  It  is  important  to  diagnose  this  before 
operating. 

Solid  tumours  of  the  ovary  are  usually  distinguished  by  being  harder 
and  smaller  than  cysts,  by  the  irregularity  of  their  form  and  the  sym- 
ptoms of  compression  of  the  pelvic  and  abdominal  organs  which  are  more 
marked  than  in  cysts;  for  the  latter  on  account  of  their  globular  form, 
their  elasticity,  &c.,  are  displaced  more  easily.  Benignant  tumours, 
such  as  fibroids,  are  tolerated  as  easily  as  cysts,  the  general  symptoms 
which  they  produce  being  more  dependent  on  their  size  than  on  their 

1  Craveilhier,  Anat.  path,  gvn.,  v,  p.  191. 

2  Puistienne,  op.  cit.,  p.  12. 

^  Cruveilhier,  quoted  by  Puistienne,  op.  cit.,  pp.  31  and  36. 


748  UTERINE    DISEASES    IN    DETAIL 

reaction  on  the  economy.  Malignant  tumours,  cancerj  scirrhus,  euce- 
phaloid,  colloidj  rarely  reach  the  size  of  cysts,-^  and  are  nodulated  and 
constituted  by  the  aggregation  of  multiple  tumours  of  variable  size 
and  consistency,  forming  globular  excrescences  of  the  ovary  rather 
than  a  regularly  rounded  tumour.  They  compress  the  neighbouring 
organs  more  and  have  more  intimate  relations  with  the  uterus.  They 
more  frequently  determine  cedema  in  the  lower  limbs  or  anasarca,  as 
well  as  ascites  and  partial  peritonitis. 

111.  Complications  of  ovarian  cysU  and  their  relations  with  the 
neighbourhig  parts. — 1.  The  principal  complications  of  ovarian  cysts 
are  the  following :  rupture,  which  when  preceded  by  adhesions  with 
the  neighbouring  parts,  by  discharging  the  fluid  incessantly  into  the 
peritoneum  may  induce  the  cure  of  a  unilocular  cyst ;  but,  if  produced 
suddenly,  it  gives  rise  to  acute  peritonitis,  and  if  the  fluid  is  discharged 
into  an  adherent  organ  (bladder,^  intestine,  vagina,  abdominal  wall, 
&c.)  the  patient  succumbs  to  suppuration  or  septicaemia.  Haemorrhage 
may  be  suspected  from  the  occurrence  of  symptoms  of  internal  hsemor- 
rhage ;  but  it  can  only  be  diagnosed  by  the  sanguinolent  appearance  of 
the  fluid  withdrawn  by  puncture.  Partial  or  general  inflammation  is 
recognised  by  the  symptoms  of  ovaritis ;  by  rigors,  feverish  attacks 
symptomatic  of  suppuration,  by  the  pains,  nausea  and  tympanitis  which 
accompany  the  development  of  peritonitisj  &c.  Ascites  may  conceal 
the  presence  of  an  ovarian  cyst  when  the  peritoneal  cavity  is  much 
distended  by  the  fluid ;  it  is,  however,  seldom  that  some  of  the  charac- 
teristic signs  of  these  two  maladies  are  not  observed  simultaneously, 
especially  in  emptying  either  the  peritoneal  fluid  or  the  contents  of  the 
cyst.  The  simultaneous  existence  of  pregnancy  and  an  ovarian  cyst 
may  be  very  difficult  to  diagnose  in  the  first  period  of  gestation,  espe- 
cially if  the  cyst  has  existed  for  some  time  and  has  attained  a  consi- 
derable development ;  later  on,  the  characteristic  signs  of  the  presence 
of  the  fcetus  leave  no  doubt.  The  simultaneous  existence  of  a  cyst 
and  of  another  tumour,  whether  uterine,  ovarian  or  independent  of  the 
genital  organs  is  more  easily  determined  at  the  commencement  of  the 
development  of  the  two  tumours,  especially  when  the  tumour  which 
complicates  the  cyst  comes  from  some  organ  situated  at  a  distance 
from  the  ovary. 

2.  The  relations  of  the  cyst  with  the  neighbouring  parts  are  perceived  on 
the  patient  assuming  different  postures,  by  raising  the  cyst  in  difterent 
directions,  either  through  the  abdominal  wall  or  by  the  vagina,  by 
pushing  it  by  graduated  pressure  in  a  certain  direction,  by  examining 
the  woman  when  standing  and  observing  the  tympanitic  note  between 
the  diaphragm  and  the  upper  surface  of  the  cyst,  by  ascertaining  that 
the  various  displacements  do  not  produce  pain,  and  lastly  by  observ- 
ing the  retraction  of    the   cyst  after  puncture  and  evacuation  of  its 

'  Clarens,  however,  once  found  in  a  woman  of  42  a  medullary  sarcoma  of  the 
left  ovary  weighing  80  lbs.  {Deutsche  Klinik,  1873,  No.  3),  and  I  have  dis- 
sected one  of  more  than  50  lbs.  in  weight. 

*  Breisky  of  Berne  {Revue  de  Haijem.  v,  178).     Eupture  of  ovarian  cyst  into 
he  bladder,  with  which  adhesions  had  been  formed. 


OVARIAN    CYSTS  749 

contents.  We  may  then  be  almost  certain  of  the  independence  of  the 
cyst ;  besides,  deep  adhesions  of  the  pelvic  cavity  seldom  exist  in 
the  absence  of  abdominal  adhesions.  The  spontaneous  pain,  on  the 
contrary,  experienced  previously  by  the  patient  at  those  spots  where 
mobility  of  the  tumour  is  doubtful  or  absent,  the  other  symptoms  of 
peritonitis,  whether  circumscribed  or  otherwise,  having  possibly  been 
already  developed,  the  acute  pains  of  dragging  or  tearing  produced  by 
attempts  made  to  remove  the  cyst  from  the  organs  to  which  it  seems 
to  adhere  (from  the  liver,  spleen,  abdominal  wall  and  iliac  fossa),  the 
impossibility  of  verifying  this  separation  after  repeated  ineffectual 
attempts,  the  pain  experienced  by  patients  either  from  a  full  or  empty 
stomach,  from  the  peristaltic  movements  of  the  intestine  during  di- 
gestion and  from  the  contractions  of  the  rectum  for  the  expulsion  of 
foetal  matters,  are  symptoms  which  prevent  us  from  making  a  mistake 
as  to  the  existence  of  adhesions  between  the  cyst  and  the  parts  with 
which  it  is  in  contact.  According  to  Koeberle  abdominal  adhesions 
are  observed  more  especially  round  the  umbilicus ;  adhesions  to  the 
epiploon  are  known  by  the  absence  of  vibrations  at  this  point ; 
adhesions  to  the  liver,  diaphragm  and  edge  of  the  ribs  can  only  be 
ascertained  by  puncture  ;  those  with  the  intestines  cannot  be  diagnosed 
beforehand,  even  under  such  conditions ;  those  with  the  pelvic  cavity 
are  recognised  when  the  cyst  cannot  be  pushed  back  into  the  abdomen, 
even  after  puncture. 

Shortness  of  the  pedicle  may  be  presumed  from  the  impossibility  of 
raising  the  tumour  in  the  abdomen  or  of  imparting  to  it  the  slightest 
movement,  from  the  defective  mobility  of  the  uterus,  from  the  presence 
of  globular  tumours  in  the  cavity  behind  or  around  the  uterus,  pro- 
jecting more  or  less  into  the  vagina,  contributing  to  fix  the  womb 
and  experiencing  a  direct  reaction  from  movements  transmitted  to  the 
cyst.  When  the  pedicle  is  long,  the  tumour  is  sufiiciently  raised 
above  the  pelvis  to  prevent  the  finger  reaching  more  than  a  spheroidal, 
broad  surface,  more  or  less  independent  of  the  uterus,  which  has  pre- 
served to  some  extent  its  mobility. 

Treatment. — Medical  treatment  ought  to  be  tried,  for  there  are  ex- 
amples of  spontaneous  absorption  of  the  contents  of  the  cyst  followed 
by  cure,  but  they  are  very  rare.  No  one  knows  better  than  I  do  the 
resistance  usually  offered  by  ovarian  cysts  to  all  medical  treatment. 
Nevertheless,  I  have  never  undertaken  ovariotomy  without  having 
previously  tried  all  other  rational  means  of  treatment,  and  have  been 
so  fortunate  as  to  see  the  use  of  these  means  succeed  in  two  very 
characteristic  cases^  in  which  I  had  little  hope  that  resolvent  treatment 
would  prove  effectual.  The  treatment  employed  in  these  cases  may  be 
summed  up  as  follows  :  chloride  of  gold  and  sodium,  from  two  milli- 

*  Large  right  ovarian  cyst,  probably  unilocular,  wbicb  had  never  been  punc- 
tured,  in  a  single  woman  of  43  ;  circumference  of  the  abdomen  at  the  umbilicus, 
one  yard.  Cure  eight  years  ago.  Right  ovarian  cyst,  apparently  multilocular, 
never  punctured,  in  a  child  of  12  who  had  never  menstruated  ;  circumference 
of  the  abdomen  at  the  umbilicus,  f  yard.  Cure  six  years  ago.  The  enormous 
size  of  the  cysts  in  both  cases  authorised  the  presumption  that  they  were 
ovarian  and  not  connected  with  the  Wolffian  bodies  or  the  broad  ligaments. 


750  UTEEINE    DISEASES    IN    DETAIL 

grammes  to  five  centigrammes  daily ;  tonics  and  restoratives,  iron, 
bark,  &c. ;  solvents,  Yichy  water,  bicarbonate  of  soda ;  resolvent  ab- 
dominal frictions  of  iodide  of  lead  and  potassium ;  diuretics,  squills, 
digitalis,  nitre ;  lastly,  and  above  all,  methodic  and  increasing  com- 
pression of  the  whole  abdominal  surface  by  means  of  Bourjeaurd's^ 
excellent  elastic  belts.  In  other  patients  (about  a  twentieth  of  the 
whole)  the  cyst  has  appeared  to  remain  stationary  or  even  to  diminish 
in  size  for  some  time  under  the  influence  of  this  treatment  (sometimes 
preceded  by  the  evacuation  of  the  fluid),  which  was  tolerated  for 
several  years  without  seriously  injuring  the  health  of  patients  affected 
by  them. 

Torsion  of  the  pedicle  of  the  tumour  is  another  means  of  spon- 
taneous cure.  It  may  extend  from  half  to  two  and  a  half  turns,  and 
is  probably  dependent  on  movements  made  by  the  patient  while  lying 
and  while  the  tumour  is  still  small.  Cysts  and  even  fibrous  tumours 
of  the  ovary  sometimes  undergo  natural  torsion  round  their  axis, 
which  may  explain  spontaneous  cure.  This  torsion,  recently  de- 
scribed by  Eokitansky  and  Klob,^  has  been  attributed  by  the  latter 
(after  experiments  made  on  a  dead  body  to  the  ovary  of  which  he  had 
attached  a  membranous  sac  of  the  size  of  an  orange)  to  the  rotation 
imparted  to  the  ovary,  always  in  the  same  direction,  by  the  alternate 
repletion  of  the  bladder,  which  makes  the  sac  turn  from  within 
outwards,  and  depletion  of  this  organ,  which  lets  it  fall  without 
turning  in  the  opposite  direction.  Tor  this  effect  to  be  produced  the 
sac  must  be  attached  to  the  external  side  of  the  ovary ;  if  on  the  in- 
ternal side  the  same  effects  are  produced,  but  in  the  opposite  direc- 
tion. It  is  accompanied  by  strangulation  of  the  vessels  of  the  pedicle, 
the  result  being,  according  to  Koeberle,  congestion  of  the  cyst,  in- 
ternal haemorrhage,  inflammation  and  even  mortification  of  the  cyst, 
and  complete  rupture  of  the  pedicle.  Unfortunately  we  cannot  help 
nature  in  accomplishing  this  singular  phenomena. 

The  natural  evacuation  of  the  contents  externally,  after  the  forma- 
tion of  salutary  adhesions,  may  produce  cure,  amelioration  (especially 
when  the  cyst  is  evacuated  through  the  vagina  or  abdominal  wall),  or 
inflammation  of  the  sac,  septicsemia  and  death  (especially  in  cases 
where  the  cyst  opens  into  the  intestine  or  bladder). — Rupture  with 
effusion  of  the  fluid  into  the  closed  cavity  of  the  peritoneum  is  still 
more  frequently  a  cause  of  death  ;^  Thomas  Keith  (the  Lancet,  10th 
March,  1877)  has,  notwithstanding,  performed  ovariotomy  successfully 
in  a  case  of  rupture ;  it  is  the  result  of  a  suppurative  inflammation, 
gangrene  of  the  cyst,  traumatism,  or  puncture.  Chereauhas  collected 
70  cases  of  rupture  of  ovarian  cysts  with  effusion  of  fluid  into  the 
peritoneum,  or  evacuation  through  the  bladder,  uterus,  vagina,  and 
abdominal  wall.  Puech,  by  collecting  33  additional  cases,  has  raised 
the  total  number  of  these  ruptures  to  103  ;  out  of  this  number  there 
were  33  deaths,  22  ameliorations,  and  48  cures  ;  as  examples  of  the 

'   'Note  sur  les  kystes  de  I'ovaire ;  Bulletin  de  I'Acad.  de  ined.,  1857. 

2  (Esterreicliische  Zeitschrift,  No.  18,  1865. 

^  Spiegelberg  has  recorded  three  new  cases  {Archiv  fur  Gyndk.,  1870). 


OVAEIAN    CYSTS  751 

latter  Richard^  has  added  5  cases  to  some  others  already  known  of 
communication  between  the  ovary  and  Fallopian  tube,  and  of  the 
evacuation  of  the  fluid  by  this  means. ^  We  have  therefore  still  less 
hope  from  this  mode  of  natural  termination  or  its  imitation  than  from 
torsion  of  the  pedicle. 

Inflammation  may  attack  the  internal  membrane  of  the  cyst  making 
the  contents  purulent,  or  it  may  extend  from  the  sac  to  the  entire 
ovary  and  be  propagated  to  the  peritoneum,  determining  adhesions  or 
suppuration.  Whether  spontaneous  or  excited  by  a  puncture,  injection 
of  iodine,  a  seton,  &c.,  as  has  too  often  happened,  it  is  soon  fatal. 
Recovery  after  such  an  accident  is  quite  exceptional.  Exhaustion  is 
the  usual  termination;  most  frequently,  the  progress  of  the  tumour 
alone  suffices  to  cause  a  daily  increasing  emaciation,  exciting  a  hectic 
fever  which  consumes  the  strength  of  the  patient,  throwing  her  into  a 
state  of  marasmus  quickly  followed  by  death.  The  physician  therefore 
has  to  do  with  a  tumour  which  may  be  developed  at  any  age,  making 
continuous  and  usually  rapid  progress  and  resisting  all  treatment, 
whilst  occupying  an  organ  the  preservation  of  which  is  not  necessary 
to  life  and  the  ablation  of  which  is  the  only  means  of  obtaining  definite 
cure. 

We  shall  now  compare  the  various  means  of  surgical  treatment, 
some  of  which  (puncture,  aspiration,  injection,  drainage,  seton, 
incision,  excision)  usually  only  procure  a  palliation  of  the  evil  whilst 
seriously  endangering  life,  whilst  others,  on  the  contrary  (extirpation), 
without  being  really  more  dangerous,  offer  the  hope  of  radical  cure. 

I.  Puncture. — This  is  a  purely  palliative  means  which  alleviates  the 
patient  temporarily  when  threatened  with  asphyxia  and  helps  the 
diagnosis.  But  this  operation,  although  apparently  simple,  is  not  free 
from  danger.  Death  may  occur  instantaneously  from  syncope  or 
haemorrhage,  or  at  a  later  period  from  peritonitis  or  from  inflammation 
of  the  sac  and  suppuration  in  the  cyst,  or  from  the  rapid  reproduction 
of  the  fluid.  Puncture  ought  therefore  to  be  deferred  as  long  as 
possible,  as  it  is  evident  that  additional  punctures  will  probably  be 
necessary  at  increasingly  shortened  intervals,  the  patient  at  last  suc- 
cumbing to  exhaustion.^  When  it  has  been  decided  on  we  must  make 
sure  that  the  patient  is  not  pregnant  and  that  there  is  no  urine  in  the 
bladder.  This  operation  is  usually  performed  with  a  large  trocar  on 
account  of  the  consistency  and  viscosity  of  the  fluid.  It  is  usually 
made  on  the  abdomen,  on  the  linea  alha,  in  the  centre  of  the  space 
separating  the  umbilicus  from  the  pubis  :  at  that  point  there  is  no  fear 
of  encountering  the  vessels  of  the  abdominal  walls  and  still  less  chance 
of  opening  one  of  the  large  arteries  which  rise  from  the  base  of  the 
cyst  and  ramify  in  it.     Tt  must  be  previously  ascertained  by  ausculta- 

'  Sur  les  Jcystes  tubo-ovariques  {Mem.  cle  la  Soc.  cle  chirurg.,  1853,  t.  iii, 

"  Nepveu  {Ann.  cle  Gynec.,  t.  iv,  p.  14,  juillet,  1875). — Brjzan  {Dissertaf. 
inavgurale.  Halle,  1875). 

•^  Vast  {Soc.  de  chirurg.,  1875). — Bczard  {Bulletin  cle  la  Soc.  mecl.  d'emula- 
tion,  1815.  Revue  de  Hayem,  vi,  1G8). 


752  UTEEINE    DISEASES    IN    DETAIL 

tion  that  there  is  no  vascular  souffle  at  this  point.  Care  should  be 
taken  to  compress  the  abdomen  strongly  when  the  fluid  is  evacuated, 
either  by  means  of  my  belt  or  by  that  of  Bourjeaurd.  If  haemorrhage 
occurs  it  should  be  arrested  by  means  of  acupressure,  applied  according 
to  SimpsonV  ingenious  method.  The  cannula  invented  by  Panas  may 
be  used  in  puncturing  ovarian  cysts  in  order  to  avoid  accidents  from 
haemorrhage  and  from  the  escape  of  liquid  into  the  peritoneum. 

II.  Aspiration. — Buys^  has  recently  proposed  sustained  aspiration 
in  order  to  provoke  the  continuous  discharge  of  fluid  and  retraction  of 
the  cyst  whilst  preventing  the  entrance  of  air  and  the  development  of 
inflammation  and  suppuration  in  the  sac,  these  accidents  having  led  to 
the  abandonment  of  the  plan  of  leaving  a  cannula  in  the  wound.  In 
place  of  aspirating  the  fluid  suddenly  and  only  at  intervals,  as  can  be 
done  by  means  of  the  instruments  invented  by  Monro,  Guerin,  and 
Boinet,  it  should,  according  to  Buys,  be  aspirated  slowly  but  con- 
tinuously and  with  increasing  force  so  as  :  1st,  to  evacuate  the  tumour 
slowly  and  prevent  the  patient  from  being  inconvenienced  by  a  too 
sudden  raptus ;  2ndly,  to  maintain  the  vacuity  of  the  cyst  by  a  more 
energetic  suction,  aspirating  each  drop  of  serum  as  soon  as  it  is  formed 
and  thus  exciting  contraction  of  the  sac ;  3rdly,  to  stimulate  the  retrac- 
tion of  the  cyst,  producing  an  exudation  of  plastic  lymph  fitted  to  make 
the  opposite  surfaces  of  its  internal  wall  adhere  together.  It  is  useless 
to  describe  the  trocar  a  ciirseur,  or  the  sort  of  india-rubber  bags  of 
different  degrees  of  thickness  invented  by  this  surgeon  to  increase  the 
strength  of  aspiration  gradually,  experience  not  having  yet  decided  as 
to  the  value  of  this  method. 

III.  Bar  ill's  cannula. — A  cannula  for  perforating  the  abdomen  and 
cyst  at  two  points  so  as  to  remain  there  without  allowing  the  sac  to 
become  separated  from  the  abdominal  wall,  was  first  proposed  by  Barth,^ 
and  was  the  subject  of  the  academic  discussion  on  ovarian  cysts  and  of 
Bauchet's  paper.  The  simple  seton  and  Chassaignac's^  drainage  are 
only  different  ways  of  carrying  out  the  same  method,  and  can  none  of 
them  be  applied  without  risking  the  danger  of  the  entrance  of  air, 
inflammation  of  the  sac,  destructive  suppuration,  &c.  I  think  that  in 
the  small  number  of  cases  in  which  they  have  been  employed  they  have 
always  been  followed  by  death. 

IV.  Iodine  injections. — Iodine  injections  preceded  and  followed  by 
other  injections  (gas,  hot  wine,^  solution  of  nitrate  of  silver,  weak 
solution  of  caustic  potash  or  tincture  of  cantharides,^  or  an  alkaline 

^  Acupressure,  a  Naw  Method  of  Arresting  Surgical  Hemorrhage  and  of 
Accelerating  the  Healing  of  Wounds.  Edinburgh,  1864 

2  Journal  de  medecine  et  de  chirurgie,  t.  xl,  33.  Bruxelles,  1865. — Traite- 
ment  des  Tcystes  de  I'ovaire,  du  pyothorax,  de  I'hydrothorax,  des  plaies,  &c., 
par  la  compression  et  I'aspiration  continues,  procedes  et  appareils  nouveaux, 
by  Buys.  Bruxelles,  1870. 

^  Bulletin  de  I' Acad,  de  med.,  xxi,  583.  Pai'is,  1855-6. 

•*  Soc.  de  chirurg.,  27  Nov.,  1861. 

5  Holscher,  Archiv,  1838,  i,  224. 

'  OUenroth,  London  Med.  Gaz.,  1835. 


OVARIAN    CYSTS  753 

sulphite^)^  have  been  employed  and  recommended  by  Boinet.-  But 
iodine  injections  can  only  be  attempted  with  any  chance  of  success  in 
the  case  of  unilocular  cysts  containing  a  serous  fluids  and  success  even 
then  is  so  doubtful  that  Boinet  himself  seems  to  be  converted  to 
ovariotomy. 

V.  Incision  and  excision. — These  are  still  less  acceptable  methods  ; 
their  object  usually  is  to  provoke  suppuration  of  the  cyst  and  that  is 
enough  to  condemn  them.  It  is  evident  that  before  incising  the  cyst, 
adhesions  should  be  estabhshed  by  only  incising  as  far  as  the  peri- 
toneum, as  advised  by  Graves  in  1827  for  abscesses  of  the  liver,  and 
by  Begin  ^  in  1830  for  all  fluid  collections  in  the  abdomen,  or  by 
making  successive  cauterisations  of  the  walls  of  the  abdomen  and  cyst 
as  performed  by  Uecamier  in  the  same  circumstances.  Supposing, 
however,  that  inflammation  and  suppuration  are  not  developed  in  the 
cyst  and  that  we  may  hope  for  amelioration  and  contraction  of  the  sac, 
we  must  never  count  on  a  definite  cure  as  long  as  there  is  a  fistulous 
opening.  The  excision  of  a  portion  of' the  walls  of  the  cyst,  the  object 
of  which  is  to  allow  the  contents  to  be  evacuated  into  the  peritoneum 
in  order  to  be  reabsorbed,  or  rather  to  provoke  suppuration  there,  is 
an  almost  necessarily  fatal  operation  ;  therefore  it  has  only  been  per- 
formed in  cases  in  which  extirpation  has  been  undertaken  and  could 
not  be  finished,  owing  to  the  adhesions  being  too  strong  or  too 
numerous. 

VI.  E^iucleation.  —  Miner  of  Buffalo  {Americ.  Journ.  of  Med. 
Science,  October,  1872)  proposed  ovariotomy  by  enucleation,  with- 
out clamp,  ligature  or  cauterisation,  a  method  which  he  had  been  led  to 
adopt  by  chance  (Hayem,  Revue  des  Sciences  med.,  i,  200).  He  per- 
formed it  thrice  without  haemorrhage,  but  he  lost  two  patients.  Meade, 
of  Bradford,  has  published  a  successful  case,  and  Gaillard  Thomas  three. 
Enucleation  has  also  been  performed  by  Logan  and  Ford  (Hayem,  id., 
1873,  p.  748),  and  by  Burnham  {id.,  id.).  It  is  certainly  very 
w^onderful  to  be  able  by  one  simple  dissection,  one  detachment  gradu- 
ally effected,  to  enucleate  a  cyst  entirely  without  having  to  cut  the 
pedicle  or  to  ligature  any  vessel.  This  operation  is  probably  only 
practicable  for  cysts  of  the  broad  ligament  (Rosen miiller's  organ  or 
others),  enclosed  between  the  two  layers  of  this  great  peritoneal  fold, 
without  pedicle  and  without  vascular  connections,  and  should  not 
be  attempted  in  the  case  of  other  tumours.  If  the  cyst  upon  which  we 
intend  to  operate  by  enucleation  has  a  pedicle,  and  if  lipemorrhage 
occurs  it  should  be  arrested  by  one  of  the  means  which  I  shall 
describe  when  treating  of  ovariotomy, 

VII.  Ovariotomy. — However  serious  this  operation  may  appear,  it 
is  now  so  well  managed  that  in  spite  of  the  gravity  imparted  to  it  by 
the  size  and  connections  of  the  tumour,  and  in  spite  of  other  unfore- 
seen dangers,  it  takes  an  increasingly  important  place  among  surgical 

'  Gritti,  Annali  universali  di  medicina,  1864,  p.  272. 

2  lodotherapie,  ou  de  I'emploi  medico-chirurgical  de  I'iode  et  de  ses  com- 
poses, 2^  edit.,  p.  531.  Paris,  1865. 

3  Journal  liebdom.  de  med.,  i,  417.  Paris,  1830. 

48 


754  UTERINE    DISEASES    IN    DETAII^ 

operations.  In  comparing  ovariotomy  with  the  other  major  opera- 
tions we  find  by  statistics  that  the  rate  of  mortality  is  lower  than  in 
operations  for  strangulated  hernia,  than  in  lithotomy  in  the  adult, 
ligature  of  the  subclavian,  &c. ;  i.e.  than  in  all  the  great  surgical 
operations  indicated  and  performed  daily  for  incurable  lesions  for  which 
they  afford  the  only  chance  of  recovery  to  the  patient.  The  comparison 
would  not  be  justifiable  if  ovarian  tumours  were  curable  by  less  dangerous 
operations ;  but  with  the  exception  of  a  few  cases  which  may  be  treated 
by  puncture  or  iodine  injections,  ovarian  cysts,  especially  those  that 
are  multilocular  and  complicated  by  the  presence  of  solid  tumours, 
are  necessarily  fatal  within  a  variable  but  short  period.  Death  is 
advanced  rather  than  retarded  by  punctures  and  iodine  injections. 
Extirpation  therefore  is  the  only  chance  of  safety  for  patients.  Not 
only  is  the  rate  of  mortality  greatly  diminished,  but  peritonitis,  the 
accident  most  to  be  feared,  has  become  much  rarer,  experience  having 
proved  that  extensive  wounds  of  the  peritoneum  are  not  necessarily 
fatal.  It  is  more  than  forty  years  ago  since  Blundell,  in  a  paper 
printed  in  his  I'hysiological  Researches,  tried  to  prove  that  the  danger 
of  peritonitis  consecutive  to  local  lesions  was  exaggerated,  and  he 
appealed  from  the  opinion  of  his  contemporaries  to  that  of  posterity. 
When  we  consider  the  large  wounds  made  by  MacDowel,  Walne, 
Clay,  Koeberle,  Pean  and  others,  in  order  to  allow  of  large  tumours 
being  extracted  from  the  abdominal  cavity  without  previous  puncture, 
we  cannot  doubt  the  comparative  tolerance  of  the  peritoneum  for 
long  incisions.  It  is  true  that  we  regard  the  reduced  size  of  the 
incisions  as  a  progress ;  but  the  incision  itself  does  not  seem  to 
have  a  direct  influence  on  the  development  of  peritonitis.  Spencer 
Wells  has  recently  proved  by  his  remarkable  success,  not  only  that 
peritonitis  is  not  necessarily  developed  after  operation,  but  further, 
that  pre-existing  peritonitis  or  even  the  complication  of  pregnancy,  do 
not  necessarily  contra-indicate  ovariotomy  when  performed  by  a  skilful 
surgeon.  However  exceptional  this  success  may  be  it  is  too  remark- 
able not  to  be  recorded  here.^ 

We  have  now  to  consider  the  question  of  the  indications  and  contra- 
indications for  ovariotomy. 

1.  The  indications  become  increasingly  easy  to  determine.  In  this 
respect  there  are  tumours  which  may  be  left  to  themselves  ;  there  are 
some  which  may  be  treated  by  puncture  or  iodine  injections ;  and 
others  which  should  be  extirpated ;  whilst  there  are  some  which  the 
surgeon  should  leave  alone  for  fear  of  compromising  surgery  by  under- 
taking impossible  operations.  It  is  right  to  remark  that  neither 
puncture  nor  injections  on  the  one  hand  nor  ovariotomy  on  the  other 
ought  to  be  applied  to  the  treatment  of  all  ovarian  cysts  indiscrimi- 
nately, and  it  would  be  wrong  to  compare  the  results  of  the  one 

^  Case. — Ovariotoinfiy  performed  successfully  in  the  fourth  month  of  pregnancy 
after  rupture  of  the  cyst  and  peritonitis  (the  Lancet,  Sept.  18,  1869. — Lyon 
medical,  7  Nov.,  1869).  There  are  several  other  cases  on  record  of  ovariotomy 
performed  during  pregnancy  {Annales  de  Cfynecologie,  viii,  153.  Paris,  1877, 
p.  1280). 


OVARIAN    CYSTS  755 

method  with  the  other  as  an  exclusive  method.  It  appears  to  me  on 
the  contrary  rational  to  make  a  distinction  between  the  cysts  to  which 
puncture  or  iodine  injections  may  be  applied,  and  those  which  require 
extirpation. — Puncture  and  iodine  injections  may  be  very  successful  in 
simple  serous  unilocular  cysts,  only  exceptionally  developing  formid- 
able and  fatal  symptoms.  If  applied,  on  the  contrary,  to  viscous, 
purulent,  complex,  multilocular  cysts  they  cannot  ameliorate  and 
usually  develop  rapidly  fatal  symptoms. — Applied  to  cysts  of  the 
first  class  ovariotomy  is  very  frequently  successful ;  but  it  is  not  indis- 
pensable, and  as  it  may  be  followed  by  formidable  accidents  inherent 
to  the  method  itself,  it  should  be  reserved  for  more  serious  cases. 
Applied,  on  the  contrary,  to  cysts  of  the  second  class,  or  to  those  of 
the  first  which  have  passed  into  the  second  from  the  ineffectual  use  of 
punctures  and  injections,  it  is  doubly  superior  to  puncture  and  injec- 
tion because  it  then  becomes  a  rational  means  of  treatment,  and 
besides  is  the  only  means  of  cure  for  a  malady  which  puncture  and 
injection  could  only  increase  and  render  rapidly  fatal. 

Therefore,  on  the  one  hand  puncture  and  injections  may  be 
attempted  in  cysts  of  the  first  kind,  because  they  may  be  curative 
means  or  at  least  sufiiciently  palliative,  while  their  failure  would  not 
absolutely  prevent  the  application  of  the  radical  method  of  extirpa- 
tion, although  lessening  the  chances  of  cure.  On  the  other  hand 
ovariotomy  is  the  only  practicable  method  for  cysts  of  the  second 
class,  to  which  puncture  is  only  applicable  as  an  exploratory  means. 
Such  is,  according  to  my  opinion,  the  limit  between  the  indication  and 
contra-indication  of  punctures  or  iodine  injections,  and  such  is  the 
limit  between  the  contra-indication  and  the  indication  for  ovario- 
tomy. 

2.  As  for  the  contra-mdications  for  ovariotomy  there  are  some 
which  may  be  drawn  from  the  age  and  strength,  or  on  the  contrary 
from  the  extreme  debility  of  patients;  but  these  are  not  only 
common  to  ovariotomy  but  to  all  operations  of  equal  gravity.  They 
are  not  of  less  consequence  on  that  account :  for  experience  proves 
that  the  danger  of  death. after  ovariotomy  depends  more  on  the 
general  state  of  health  than  on  complications  of  the  malady,  such 
as  the  size  of  the  tumour,  adhesions  and  difficulties  attending  the 
operation.^  Nevertheless,  I  shall  only  occupy  myself  with  the  special 
contra-indications  connected  with  the  operation  itself.  One  of  these 
is  the  existence  of  solid  constituents  and  especially  cancer  in  the 
tumour,  which  may  make  pediculisation  of  the  latter  impossible  or 
relapse  likely ;  hence  the  utter  inutility  of  the  operation  in  such 
cases.  I  know  that  Koeberle  has  set  an  example  which  might  be 
followed  by  removing  the  uterus  as  well  as  the  ovaries  and  so 
making  pediculisation  of  the  tumour  absolutely  possible.  Some 
day  we  shall  perhaps  enter  on  the  path  opened  up  by  Atlee  and 
Clay  for  the  extirpation  of  utero-peritoneal  fibrous  tumours.     These 

^  Spencer  Wells,  'Fifty  Cases  of  Ovariotomy,  second  series.  London,  1867  ; 
from  the  Medico -Chirurgical  Transactions,  1865. 


756  UTERINB    DISEASES    IN   DETAIL 

cases,  however,  are  too  exceptional  to  authorise  our  introducing 
into  practice  precepts  contrary  to  those  which  I  think  should  form  the 
basis  of  these  contra-indications  for  ovariotomy. 

Another  contra-indication  is  the  number,  extent  and  solidity  of 
adhesions  (especially  in  multilocular  cysts),  either  with  the  abdominal 
wall  or  viscera,  especially  with  those  which  are  high  up,  such  as  the 
stomach,  liver,  &c.  I  saw  with  Simpson  a  girl  of  15  affected  with 
an  enormous  multilocular  cyst,  with  viscous  greenish-grey  contents, 
the  puncture  of  which,  after  several  sacs  had  been  evacuated,  did 
not  determine  retraction  at  any  point,  from  the  epigastrium  to  the 
pubis  or  from  one  flank  to  the  other.  It  seemed  imprudent  to 
attempt  the  extirpation  of  such  a  tumour,  the  adhesions  of  which 
were  so  strong  and  so  extensive,  and  yet  the  operation  was  performed 
by  Keith  with  complete  success.  Such  adhesions,  with  the  existence 
of  solid  tumours,  as  well  as  errors  of  diagnosis  may  account  for  the 
operations  which  were  undertaken  by  some  of  the  first  ovariotomists, 
but  which  could  not  be  terminated. 

Lastly,  after  having  endeavoured  to  arrive  at  the  most  probable 
diagnosis  by  all  ordiuary  means,  especially  by  puncture,  we  may 
attempt  to  convert  this  probability  into  certainty  by  an  exploratory/ 
incision  ;  for  experience  proves  that,  when  carefully  done,  this  incision 
does  not  greatly  increase  the  chances  of  death.  Supposing  that  this 
last  element  of  diagnosis  is  in  favour  of  operation  the  latter  is  in  such 
a  case  already  begun,  and  the  surgeon  has  only  to  continue  it. 

Freparatory  treatment  was  considered  a  few  years  ago  to  have  more 
influence  on  the  success  of  the  operation  than  is  now  admitted.  This 
influence,  however,  although  indirect  is  not  the  less  real,  and  when  the 
operation  can  be  delayed  I  think  the  preceding  time  should  be  taken 
advantage  of  for  putting  the  patient  into  the  best  possible  conditions. 
The  best  means  for  preventing  the  most  dangerous  accidents  attending 
ovariotomy,  such  as  hseraorrhage,  debility,  suppuration  and  purulent  or 
putrid  infection  are:  strengthening  and  nourishing  diet;  residence  in 
a  bracing  climate,  baths  followed  by  frictions  and  other  hygienic  mea- 
sures ;  to  which  we  may  also  add  the  use  of  iron  and  other  tonics. 
Simpson  attached  great  value  to  the  latter  agent  in  preparing  patients 
for  operations,  and  preferred  the  tincture  of  the  perchloride.  The  use 
of  iron  preparations  should  not  be  reserved  for  the  days  previous  to 
operation ;  it  is  quite  as  useful  after  ovariotomy.  Like  all  other 
serious  operations  the  extirpation  of  ovarian  cysts  should  be  per- 
formed when  menstrual  congestion  has  entirely  passed,  i.  e.  about 
eight  days  after  the  cessation  of  the  monthly  period.  Although 
Koeberle  performed  an  operation  during  the  catamenial  period  and 
succeeded,  that  is  no  reason  for  admitting  that  there  is  not  more 
danger  in  performing  ovariotomy  then  than  at  another  time.  In  order 
that  the  intestines  may  have  rest  after  ovariotomy,  it  is  useful  to 
empty  them  not  only  by  an  enema  but  also  by  a  mild  purgative 
given  the  day  previous  to  operation.  I  agree  with  Koeberle  in 
preferring  an  ounce  of  castor  oil,  mixed  with  an  ounce  of  syrup 
of  tartaric  acid,  followed   in   the    evening    by  30    to    60    grains  of 


OVARIAN    CYSTS 


subnitrate  of  bismuth^  in  order  to  decompose  the  sulphurous  gases 
remaining  in  the  digestive  canal. 

The  first  operations  having  been  performed  before  the  discovery  of 
ausesthetics,  the  patients  were  not  able  to  have  the  benefit  of  such 
relief.  But  since  its  introduction  into  surgery  no  operator  has  failed 
to  employ  it  before  proceeding  to  the  extirpation  of  ovarian  cysts.  We 
should  remember  that  the  opening  of  a  large  cavity  like  the  abdomen 
and  its  prolonged  exposure  to  the  air  have  a  tendency  to  chill  the 
body  considerably :  therefore  the  chest  and  lower  limbs  should  be 
covered  with  warm  flannel. 

The  operation  strictly  speaking  is  divided  into  six  stages  :  abdominal 
section ;  puncture  and  evacuation  of  the  cyst ;  rupture  of  adhesions 
and  extraction  of  the  ovary ;  constriction  and  section  of  the  pedicle ; 
cleansing  of  the  abdominal  and  pelvic  cavities  ;  closing  of  the  wound. 

1.  Abdominal  section  (\x\c\\xA\u^  that  of  the  tegtinients  and  perito- 
neum) is  always  made  on  the  tinea  alba.  An  incision  of  4  or  5  inches 
at  equal  distances  from  the  umbilicus  and  pubis  suffices  as  an  explora- 


FiG.  412. — Incision  in  the  direction  of  the  linea  alba  without  touching  the 
peritoneum,  enlarged  with  scissors  guided  by  the  index  finger  or  the  direc- 
tor (after  Savage,  as  well  as  the  following  figures  relating  to  ovariotomy). 

tory  incision,  and  it  can  be  increased  when  necessary.  If  circum- 
stances require  its  being  extended  beyond  the  umbiHcus  care  should 
be  taken  to  direct  it  to  the  left  so  as  to  avoid  the  navel.  In  such 
cases  Koeberle  incises  the  umbilicus  directly,  and  if  there  is  an  umbili- 
cal hernia  he  incises  the  sac  at  the  same  time  to  obtain  a  radical  cure. 
When  the  peritoneum  is  reached  the  incision  presents  some  diffi- 
culty. The  wound  should  be  kept  dry  by  sponging  and  by  seizing 
with  artery  forceps  the  veins,  which  are  sometimes  very  much  deve- 
loped, and  which  may  give  rise  to  profuse  hemorrhage.  Next  it  is 
important  to  distinguish  the  peritoneum  from  the  wall  of  the  cyst. 


758 


UTEEINB    DISEASES   IN   DETAIL 


The  serous  membrane  is  raised  with  a  tenaculum  hook  or  mouse- 
toothed  forceps,  and  a  small  opening  is  made  through  which  an  ordi- 


/^^^^^, 


Fig.  413. — Manner  of  opening 
the  peritoneum,  whicli  is 
incised  in  the  same  direc- 
tion and  to  the  same  extent 
as  the  teguments. 


Fig.  414. — The  operator,  by  passing  his 
hand  round  in  various  directions 
between  the  tumour  and  the  peri- 
toneum, assures  himself  of  the 
extent  and  nature  of  the  adhesions 
if  there  are  any. 

nary  director  or  the  index  finger  can  pass  from  above  downwards,  the 
serous  membrane  being  divided  by  passing  a  bistoury  or  scissors  along 
the  director  so  as  to  give  the  same  extent  to  this  incision  as  to  that  of 
the  teguments. 

2.  F^mctiire  (preceded  by  separation  of  adhesions')  and  evacuation 
of  the  cyst  (^preventing  at  the  same  time  the  escape  of  the  fluid  into 
the  peritoneal  cavity)  constitute  the  second  part  of  the  operation. 
Before  performing  these  the  hand  should  be  passed  between  the  ab- 
dominal wall  and  the  cyst  to  ensure  there  being  no  adhesions,  any 
slight  ones  which  may  exist  being  ruptured  by  the  finger.  The  nature 
of  the  tumour  is  verified  at  the  same  time,  as  well  as  the  relative 
size  of  the  cysts  composing  it,  as  the  largest  and  the  one  which  should 
be  punctured  first  may  not  be  directly  opposite  the  abdominal  opening. 


Fig.  415. — Spencer  Wells's  ingenious  trocar  in  the  form  of  a  wide  tube,  bevelled 
of£  at  one  of  its  extremities  into  a  very  sharp  point  which  makes 
the  puncture  ;  towards  its  central  part  there  is  a  circular  and  notched  catch, 
into  which  fit  two  strong  semicircular  claws,  which  retain  the  cyst  on  a 
level  with  the  puncture ;  the  other  extremity  is  furnished  with  a  raised 
border,  to  which  a  large  india-rubber  tube  can  be  fastened,  allowing  of  the 
rapid  evacuation  of  the  fluid  without  its  escaping  externally. 

We  should,  however,  beware  of  using  much  force  in  separating 
adhesions,  especially  if  there  is  reason  to  suppose  that  the  wall  of  the 
cyst  is  thin,  as  there  would  be  a  risk  of  rupturing  it  and  of  determin- 
ing evacuation  of  the  whole  of  the  fluid  into  the  abdominal  cavity. 


OVARIAN    CYSTS 


759 


After  this  exploration  has  been  made  the  cyst  is  punctured.  The 
best  instrument  for  the  purpose  is  Spencer  Wells's  trocar,  the  point  of 
which  is  hollowed  out  into  a  tube,  like  the  cannula,  and  may  be  con- 
tained within  the  latter,  or  project  beyond  it  according  to  the  wish  of 
the  operator,  and  the  cannula  of  which  itself  holds  a  secondary 
cannula,  soldered  on  to  it  at  right  angles  and  furnished  with  an 
india-rubber  drainage  tube,  at  the  extremity  of  which  is  a  weight, 
directing  it  into  a  tub  placed  on  the  right-hand  side  of  the  bed  ready 
to  receive  the  fluid  from  the  cyst.  The  instrument  has  a  sufficient 
diameter  to  allow  of  the  fluid,  which  is  usually  thick  and  viscous, 
being  discharged  without  difficulty.  As  the  cyst  is  emptied  care 
should  be  taken  to  keep  the  edges  closely  applied  to  the  cannula  of 
the  trocar,  lest  the  contents  should  escape  into  the  abdomen.  Evacu- 
ation of  the  fluid  is  then  completed  without  further  precaution ;  any 
other  secondary  cyst  or  chamber,  which  is  too  much  distended  to 


Fia.  416.— Puncture  o£  the  tumour  by  means  of  the  trocar  and  syplion  cannula. 

allow  of  the  passage  of  the  tumour  through  the  abdominal  orifice,  is 
punctured  in  the  same  manner,  and  in  this  way  (unless  there  are 
solid  tumours  or  a  considerable  agglomeration  of  small  cysts)  we 
are  able  to  make  the  ovary  supple  and  mobile  enough  to  allow  of 
its  passing,  when  drawn  carefully  little  by  little,  through  the  abdomi- 
nal opening.  If  this  evacuation  is  too  slow  it  is  better  to  enlarge 
the  opening  of  the  sac  and  even  the  abdominal  incision  with  the 
bistoury,  in  order  to  facilitate  the  escape  of  the  cyst,  than  to  lose 
time  and  run  the  risk  of  haemorrhage  by^  puncturing  the  secondary 
cysts. 

3.  Extraciion  of  the  cyst  (assisted  hj  ramug  the  cyst  and  hr-eaking 


760  UTJlEINl!;  DISEASES   IN   DETAIL 

^lp  secondary  cysts,  and  especially  by  tlie  rupture  of  adhesions^  may 
be  very  simple  or  very  complicated.  The  breaking  up  of  secondary 
cysts  and  the  raising  of  the  tumour  do  not  present  serious  difficulties, 
but  it  is  different  with  regard  to  adhesions.  When  adhesions  do  not 
exist  or  are  few  and  unresisting,  extraction  of  the  cysts  is  playwork. 
When,  on  the  contrary,  they  are  numerous  and  resistant  this  part  of 
the  operation  may  become  dangerous,  necessitating  manceuvres  which 
may  afterwards  determine  serious  accidents  compromising  the  success 
of  the  operation.  When  I  have  finished  the  description  of  the  opera- 
tion I  shall  speak  of  the  conditions  which  may  make  it  impossible 
for  the  surgeon  to  terminate  it ;  but  for  the  present  I  take  for  granted 
that  it  can  be  accomplished.  This  result  is  obtained  more  frequently  than 
formerly,  as  the  operator  does  not  now  allow  himself  to  be  discouraged 
by  the  existence  even  of  very  firm  adhesions  except  that  he  leaves 


Fi&.  417.— Method  of  preventing  tbe  escape  of  the  fluid  into  the  abdominal 
cavity  from  the  opening  made  by  the  trocar.  An  assistant  with  both  hands 
aids  the  withdrawal  of  the  cyst. 

portions  of  the  cyst  on  the  organs  to  which  they  adhere.  Experience 
has  proved  that  success  may  be  obtained  even  in  apparently  very  un- 
favorable circumstances.  But  great  precautions  should  be  taken  in 
the  rupture  or  dissection  of  these  adhesions,  not  only  of  those  which 
unite  the  cyst  to  the  abdominal  wall  and  epiploon,  but  especially  of 
those  which  unite  it  to  the  intestines,  stomach,  liver,  spleen,  or 
pelvic  cavity,  to  the  uterus,  other  ovary,  bladder,  &c.  We  not  only 
run  the  risk  of  injuring  these  organs,  and  in  such  a  case  it  is 
better  to  leave  a  portion  of  the  cyst,  which  should  be  cut  off  round 
the  adhesion,  making  it  as  thin  as  possible ;  but  we  also  risk 
causing  haemorrhage,  and  this  is  why  we  should  try  to  staunch 
the  blood,  tying  all  the  djyided  vessels  which  threaten  a  secondary 
hsemorrhage,  either  on  the  epiploon,  where  this  most  frequently  occurs, 
or  elsewhere.     Sometimes  we  must  first  of  all  search  for  the  pedicle, 


OVAEIAN    CYSTS 


761 


and  ligature  it  if  possible  before  destroying  the  adhesions  in  order 
to  stop  the  hsemorrhage.     After  having  succeeded  by  this  manceuvre 


Fig.  418. — The  operator  Is  obliged 
to  complete  the  withdrawal 
of  the  cyst  by  the  introduc- 
tion of  the  other  hand  below, 
with  which  he  raises  the 
cyst. 


Fig.  419. — The  operator  reduces  the  size  of 
a  multilocular  cyst  incompletely  evacuated 
by  breaking  up  the  remaining  cysts  with 
his  hand,  which  he  introduces  into  the 
interior,  keeping  hold  at  the  same  time  of 
the  borders  so  that  the  fluid  cannot  escape 
into  the  peritoneum. 


in  isolating  the  whole  of  the  cyst,  or  in  removing  successively  the 
various  fragments  of  the  tumour  which  are  detached  (of  which  I  have 
given  examples),  the  rest  of  the  tumour  is  drawn  outside  the  abdominal 
opening,  which  can  be  enlarged  when  necessary,  and  the  pedicle  is 
seized  firmly.  At  this  difficult  and  dangerous  period  of  the  operation 
we  must  not  fear  to  give  the  necessary  time  required.  The  gravity 
of  ovariotomy  is  always  in  proportion  to  the  complications  that  it 
presents,  and  the  best  means  of  diminishing  the  influence  of  these 
complications  is  the  use  of  the  most  effectual  methods ;  now,  rupture 
of  adhesions  and  hemostasis  after  this  rupture,  either  by  momentary 
compression  (by  artery  forceps)  or  by  astringents  (alcohol,  perchloride 
of  iron,  &c.),  by  the  cautery,  or  by  metallic,  silk,  or  catgut  liga- 
ture, are  necessary  proceedings  to  prevent  troublesome  results  from 
these  local  complications.  Tlie  actual  cautery  and  the  short  ligature 
are  the  most  certain  hemostatics. 

.  4.  The  fourth  part  of  the  operation  is  the  constriction  and  section  of 
the  pedicle  which  varies  according  to  whether  the  pedicle  is  retained  in 
the  angle  of  the  wound  or  is  returned  to  the  pelvic  cavity.  It  may  be 
that  we  have  no  choice  as  to  the  various  methods  successively  emjjloyed 
to  attain  this  end,  and  if  the  pedicle  is  short,  or  if  it  cannot  be 
lengthened  artificially  by  applying  constriction  to  the  base  of  the  cyst 


762 


UTERINE   DISEASES    IN    DETAIL 


when  firmly  folded  in  place  of  applying  it  to  the  utero-tubo-ovarian 
pedicle,  it  is  necessary  to  employ  one  of  the  means  which  I  shall  describe. 
At  first  it  was  thought  better  to  keep  the  pedicle  attached  to  the  abdo- 
minal wound  and  as  much  as  possible  outside  this  wound,  in  order  to 
avoid  suppuration  in  the  pelvic  cavity.  Although  Tyler  Smith's  success 
seemed  to  remove  all  ground  for  exaggerated  fears  on  this  point 
Langenbeck  was  the  first  who  laid  down  and  applied  this  precept. 

One  suture  may  be  passed  at  once  through 
the  pedicle  and  the  two  lips  of  the  lower 
angle  of  the  wound,  or  the  pedicle  may 
be  retained  at  this  point  by  a  strong 
needle  or  it  may  simply  be  compressed 
against  one  of  the  lips  of  the  wound  or 
against  the  neighbouring  portion  of  the 
abdominal  wall  (when  it  is  too  short), 
by  means  of  the  ingenious  method  of 
acupressure  invented  by  Simpson.^  But 
the  clamp  or  clipper  invented  by  Hutchiu' 
son  in  1838  is  preferable.  Koeberle  also 
has  a  clamp,  but  he  prefers  his  serre- 
noeuds.  The  most  convenient  of  these 
instruments  is  one  which  I  have  seen 
Spencer  Wells  use.  Constriction  should 
be  made  carefully,  not  only  to  prevent 
consecutive  haemorrhage  but  also  be- 
cause tetanus  has  been  occasionally  de- 
veloped from  incomplete  constriction  of 
the  pedicle.  Cases  of  death  from 
tetanus  have  occurred  after  ovario- 
tomy. {Annales  de  G^necologie,  t.  xi, 
p.  £31.) 

Whatever  method  be  employed,  all  that 
remains  to  be  done  to  complete  the  ex- 
traction of  the  cyst  is  to  cut  the  corre- 
sponding portion  of  the  pedicle,  at  five 
or  six  millimetres  from  the  constriction. 

When  the  pedicle  is  very  short  and 
cannot  be  drawn  into  the  lower  angle 
of  the  wound  on  a  level  with  the  in- 
tegument without  considerably  twisting 
or  dragging  tlie  uterus  it  has  necessarily 
to  be  left  at  a  more  or  less  considerable 
depth.  If  it  is  thin,  if  it  can  be  com- 
pressed by  a  thread  in  one  or  two  liga- 
tures, and  if  it  can  be  cut  close  to  the 
thread,  I  see  no  reason  against  imitating  Tyler  Smith  and  letting 
it  fall   back  into   the  pelvis,  except   in   those  cases   in   which  the 

'  Acupressure,  a  New  Method  of  Arresting    Surgical  Hemorrhage,  &c. 
Edinburgh,  1864. 


Fig.  420. — Clamp,  the  handles 
of  which  may  he  re- 
moved by  the  catches, 
A  A,  It  resembles  that  of 
Spencer  Wells,  except  in 
the  absence  of  the  small 
triangular  blade  which  re- 
stores the  parallelism  of 
the  branches  when  they 
are  close  together. 


OVARIAN    OTSTS  763 

rupture  of  numerous  adhesions  may  lead  us  to  fear  the  establishment 
of  suppuration.  In  the  contrary  case,  especially  if  it  is  necessary  to 
apply  more  than  one  ligature,  or  to  extirpate  both  ovaries  and  there- 
fore to  multiply  the  ligatures,  I  think  it  is  better  to  keep  the  threads 
in  the  lower  angle  of  the  wound,  stretching  them  by  means  of  an 
india-rubber  catheter  or  director  passed  through  the  loops  of  the 
various  ligatures  and  resting  across  the  wound  so  as  to  retain  them 
with  more  or  less  force  against  the  teguments,  or  to  maintain  constric- 
tion of  the  pedicle  by  means  of  a  serre-noeud  as  Koeberle  does.^  This 
surgeon  interposes  between  the  lower  portion  of  the  lips  of  the  abdo- 
minal incision  two  valves  of  lead,  intended  to  prevent  the  occlusion  of 
the  wound  before  the  end  of  suppuration,  to  keep  open  a  kind  of  drain 
for  promoting  the  escape  of  fluid  and  pus,  and  to  isolate  this  from 
the  rest  of  the  abdominal  cavity,  and  especially  from  the  rest  of  the 
wound.  Section  of  the  pedicle  by  the  ecraseur  has  even  been  proposed 
which  would  facihtate  union  of  the  wound  and  prevent  the  drawback  of 
leaving  the  ligature  of  the  pedicle  in  its  lower  angle ;  but  I  confess 
that  I  should  be  too  much  afraid  of  secondary  haemorrhage  from  the 
arteries  of  the  pedicle  to  venture  to  prefer  this  means  to  those  just 
described,  or  to  section  of  the  pedicle  by  the  cautery,  or  to  its  return  to 
the  pelvis  with  a  short  ligature.  Netzel,  of  Stockholm,  who  has  em- 
ployed the  clamp  forty -seven  times,  and  cauterisation  eight  times,  as 


Fig.  421. — Tumour,  just  witMrawn,  is  held  by  an  assistant  so  as  to  prevent 
laceration  of  the  pedicle,  whilst  the  operator  compresses  it  in  a  metallic 
clamp  and  divides  the  pedicle  with  the  actual  cautery. 

well  as  the  silk  ligature  left  in  the  pelvic  cavity  with  the  stump  of  the 
pedicle,  prefers  the  latter  method  {Annales  de  Gijnecologie,  t.  ix,  p. 
464).     Terrier  once  found  in  a  ])atient  who  died  two  years  after  ovari- 

*  Ligature  of  the  pedicle  in  omj  or  two  masses  separated  by  double  iron  wire 
by  means  of  Kceberl6's  little  serre-noiud  may  be  adopted  as  a  general  method. 


764  UTEfilNB    DISEASES    IN    DETAIL 

otomyj  two  silver  sutures,  which  could  not  be  removed  at  the  time  of 
the  operation.  They  were  discovered  in  the  midst  of  the  cellular 
adipose  tissue  dragged  to  the  side  of  the  peritoneal  cavity  by  the 
retraction  of  the  epiploon^  not  encysted,  slightly  blackened  by  the 
sulphide  of  silver,  surrounded  on  every  side  by  adipose  cellular  tissue 
and  perfectly  tolerated;  a  fact  which  authorises  our  giving  the  preference 
to  the  short  ligature  {Annales  de  Gynecol.,  t.  vii,  p.  459).  Alban  Doran 
has  seen  exudations  of  plastic  lymph  surrounding  and  isolating  the 
pedicle  in  a  woman  of  37  who  died  of  septicsemia  six  days  after 
ovariotomy,  whilst  in  another  woman  operated  on  by  Bantock  the 
hempen  thread  had  disappeared  seven  months  after  the  operation  and 
the  pedicle  had  contracted  adhesions  with  the  epiploon  and  the  broad 
ligament  {St.  Bartholomew'' s  Hospital  Reports,  vol.  xiii,  p.  195,  1877). 
Now  that  antiseptic  precautions  are  taken  the  clamp  is  seldom  used,  the 
pedicle  being  returned  to  the  pelvis  after  having  been  compressed  by  a 
strong  ligature  which  is  cut  close  to  the  section  of  the  pedicle,  or 
cauterised  with  the  actual  cautery  whilst  constriction  is  maintained  by 
means  of  Baker-Brown^s  clamp.  This  latter  method  is  chiefly  employed 
when  the  pedicle  is  short  and  broad,  and  has  often  been  used  by 
Baker-Brown,  Krassowsky,  Pean,  and  Koeberle.  In  order  to  liberate 
the  pedicle  after  it  has  been  cauterised  the  clamp  should  be  loosened 
slowly,  and  without  shaking,  so  as  to  avoid  lacerating  the  walls  of  the 
compressed  vessels.  The  short  ligature  may  be  ot  catgut,  silk,  or 
metal,  single  or  multiple,  according  to  the  size  of  the  pedicle. 

The  other  ovary  should  then  be  examined  and  should  be  extirpated 
if  it  is  found  to  be  the  seat  of  commencing  disease.  At  other  times  it 
is  plain  from  the  beginning  that  the  case  is  one  for  double  ovariotomy. 
Winkler  of  Dresden  has  even  had  to  perform  a  triple  ovariotomy 
necessitated  by  the  presence  of  a  supernumerary  ovary  also  the  seat  of 
a  cyst  [Ann.  de  Gynecol. ,  t.  xi,  p.  74). 

5.  Cleansing  of  the  abdominal  and  pelvic  cavities.— \l\i\QQA,  cjstic 
fluid,  clots  or  fragaaents  of  the  tumour  are  still  found  in  the  peritoneal 
cavity  they  should  be  removed  most  scrupulously.  English  surgeons 
rightly  ascribe  a  great  deal  of  their  success  to  this  precaution.  There 
need  be  no  fear  of  introducing  the  hand  several  times  into  the  pelvic 
cavity  and  of  afterwards  applying  thoroughly  clean  sponges,  in  order 
to  ensure  the  peritoneum  being  perfectly  dry,  and  by  sufficient  delay  or 
the  application  of  fresh  ligatures  to  prevent  consecutive  haemorrhage. 
It  is  however  right  to  mention  that  Koeberle  is  not  so  strict  with  regard 
to  the  cleansing  of  the  peritoneum ;  he  uses  soft  napkins  and  hot  flan- 
nels in  preference  to  sponges. 

6.  The  last  part  of  the  operation  is  union  of  the  lips  of  the  wound, 
which  should  take  place  if  possible  by  first  intention.  Care  is  taken 
to  replace  the  epiploon  and  intestines  into  the  abdominal  cavity  if  they 
have  escaped.  (During  the  operation  an  assistant  is  entrusted  with  the 
task  of  pushing  them  back  with  hot  wet  flannels  whenever  they  present 
themselves  at  the  upper  angle  of  the  wound.)  The  pedicle,  well  com- 
pressed and  cauterised,  is  either  left  in  the  pelvic  cavity  or  else  main- 
tained by  the  clamp  in  the  lower  angle,  the  lips  of  the  wound  are  then 


OVARIAN    CYSTS 


765 


seized  and  the  suture  applied  in  superimposed  layers,  i.e.  a  deep  and  a 
superficial  suture.  Koeberle  used  lo  employ  the  quilled  suture  for  the 
deep  suture,  but  now  contents  himself  with  the  interrupted  suture  not 
involving  the  peritoneum.  The  simple  zigzag  suture  may  also  be  used 
after  the  manner  of  the  English  surgeons.  Spencer  Wells,  who  only 
leaves  the  sutures  in  place  for  the  few  days  necessary  for  union, 
merely  uses  ordinary  strong  thread.  The  ends  of  each  suture  are 
passed  through  the  eyes  of  two  needles  and  he  then  pushes  each  needle 
alternately  from  the  peritoneum  (at  five  or  six  millimetres  from  the 
incision)  to  the  skin  (at  the  distance  of  about  from  two  to  three  centi- 
metres from  the  wound),  he  then  secures  the  two  ends  on  the  line  of 
union.     The  sutures  are  placed  at  the  distance  of  two  centimetres  apart. 


Fig.  422.  Fig.  423. 

Pig.  422. — The  method  of  passing  the  needle  for  the  metallic  suture,  including 

the  peritoneum. 
Fig.  423. — Wound  closed,  edges  united,  pedicle  secured  hy  a  permanent  clamp. 

and  in  the  intervals  a  few  superficial  sutures  are  passed.  The  last  deep 
suture  passes  close  to  the  clamp  so  as  to  retain  the  pedicle  in  place 
without  piercing  it.  The  other  London  surgeons  whom  I  have  seen 
operate  do  not  pierce  the  peritoneum  and  make  use  of  silver  sutures. 
Simpson  employed  iron  wire,  which  he  left  indefinitely  in  the  wound. 
Like  Spencer  Wells,  Simpson  and  Keith  included  the  peritoneum  in 
the  suture,  and  I  have  always  done  the  same.  Since  1874  Kreberle 
leaves  the  peritoneum,  only  piercing  the  fibrous  tissues  by  a  deep  inter- 
rupted suture,  the  ends  of  which  directly  cross  the  wound,  and  he  uses 
a  harelip  suture  to  unite  the  skin.  The  pins  of  this  harelip  suture 
only  remain  in  place  for  twenty-four  hours  and  are  then  replaced  (with 
the  exception  of  the  last  which  remains)  by  a  dry  collodion  suture  which 
remains  solid  for  four  weeks.  The  deep  sutures  fall  from  the  eighth  to 
the  fifteenth  day. 

We  have  now  to  speak  of  the  immediate  results  of  ovariotomy  as 
regards  the  operation  and  the  means  for  preventing  or  overcoming 
accidents.  The  knowledge  of  these  means  is  all  the  more  important, 
as  all  ovariotomists  agree  in  thinking  that  it  is  to  the  after-treatment, 
in   a    great  measure,  that  the  success  of  the  operation  is  due.     Acci. 


766  UTERINE    DISEASES    IN  DETAIL 

dents  may  occur  even  during  operation.  Nussbaum  once  divided  the 
right  ureter ;  Simon  and  Tauffer  of  Pribourg  the  left  ureter  {Annates 
de  Gynec,  vii,  466.  Paris^  1877).  Nussbaum  made  an  artificial 
ureter,  Tauffer  sutured  the  upper  border  of  the  bladder,  and  the 
patient  recovered ;  Simon  performed  nephrotomy  successfully. 
Chambers  wounded  the  intestine  and  cured  it  by  a  continued  suture 
two  inches  in  length  ;  in  another  case  of  intestinal  wound  he  was 
equally  successful  {Lancet,  1877,  p.  312).  Lyon  {Glasgow  Med. 
Journ.,  1868)  has  seen  an  abnormal  anus  formed  after  an  intestinal 
wound  which  in  spite  of  energetic  treatment  was  not  cured  at  the  end 
of  a  year.  Keith  {Glasgow  Med.  Journ.,  1869,  No.  2)  has  seen  an 
intestinal  fistula  origuiating  in  the  same  way  and  persisting  after 
twenty-five  months.  Spencer  Wells  (id.,  No.  86),  Atlee  {American 
Journ.  of  Med.  Science,  1872),  and  Hennig  {Archiv  fur  Gynaec, 
iii,  287)  have  observed  analogous  cases.  Heath  {Lancet,  1871, 
Nos.  4  and  11)  has  seen  an  abnormal  anus  follow  an  intestinal  wound 
made  directly  with  scissors.  Elischer  {Centralblatt  f.  Gynaecol.,  1877, 
p.  204)  has  observed  an  analogous  case  :  the  wound  was  sutured,  cure 
following  immediately.  Pean  has  twice  wounded  the  intestine :  in 
such  cases  the  wound  should  be  united  with  sutures  of  carbolised  cat- 
gut, and  this  portion  of  the  intestine  must  be  retained  near  the  lower 
angle  of  the  wound,  as  in  Chambers's  case.  If  the  bladder  is  injured 
the  edges  should  be  sewed  together  and  a  catheter  left  in  the  urethra. 
This  accident  happened  to  Lauffer  once  and  the  patient  recovered ; 
to  Pean  once,  his  patient  also  recovered  ;  once  to  Henry  Smith,  when  the 
accident  ended  fatally  ;  twice  to  Spencer  "Wells,  one  patient  recovered, 
the  other  died ;  three  times  to  Thornton,  in  two  cases  recovery  was 
rapid,  the  other  patient  died ;  once  to  Bantok,  the  patient  died ;  once 
to  Eustache,  when  the  patient  recovered  (Eustache,  De  la  lesion  des 
organs  icrinaires  pendant  I'operation  de  Vovariotomie.  Journ.  des 
Sciences  med.  de  Lille,  1880). 

The  most  formidable  accidents  after  operation  are :  shock,  exhaustion, 
haemorrhage,  accumulation  of  pus,  purulent  infection,  and  lastly  peri- 
tonitis, which  according  to  some  surgeons  is  the  most  frequent  accident, 
whilst  Spencer  Wells,  on  the  contrary,  thinks  it  rarer  than  either  puru- 
lent or  putrid  fever,  or  exhaustion.  According  to  Marion  Sims  septi- 
Ccemia  is  the  most  frequent  cause  of  death;  therefore  he  advises 
perforation  of  Douglas's  cul-de-sac  and  Lister's  antiseptic  dressings. 

Anaesthesia  is  one  of  the  best  means  of  preventing  shock ;  when 
it  occurs  the  patient  should  be  covered  with  flannel  and  have  hot- water 
bottles  placed  at  the  extremities  to  warm  her ;  anti-spasmodics  may 
be  administered  when  necessary,  or  stimulants,  such  as  wine,  brandy, 
carbonate  of  ammonia.  Exhaustion  should  be  prevented  by  perfect 
rest  and  by  giving  small  quantities  of  beef  tea  and  wine,  as  well  as 
tonics,  remembering  that  the  risk  of  hemorrhage  and  peritoneal  in- 
flammation requires  us  to  prescribe  a  somewhat  strict  diet  for  some 
days  in  order  to  give  absolute  rest  to  the  digestive  canal,  Tyler  Smith 
carries  precautions  so  far  as  to  leave  a  catheter  in  the  bladder  in  order 
to  avoid  the  movements  necessitated  by  micturition.     Uterine  and  in- 


OVARIAN    CYSTS  767 

testinal  cramp,  hiccough  and  vomiting  may  be  developed,  placing 
patients  in  danger  by  rupturing  sutures,  and  the  same  may  be  said  of 
tympanitis.  They  should  be  soothed  by  means  of  chloroform  or  other 
ansestheticSj  and  antispasmodics.  In  order  to  prevent  the  fluxionary 
abdominal  movements,  which  may  determine  haemorrhage,  or  the  deve- 
lopment of  peritonitis,  Kceberle  applies  ice  to  the  abdomen  in  two 
bladders  placed  one  on  each  side  of  the  wound  for  a  few  days.  I'have 
never  seen  this  precaution  used  by  English  surgeons,  and  their  patients 
do  not  succumb  any  oftener  than  others  to  the  accidents  which  the  con- 
tinuous application  of  ice  seems  fitted  to  prevent.  It  is  of  great 
importance  to  ensure  rest  to  the  intestines  and  to  prevent  all  movement 
and  dragging  in  the  belly  which  could  draw  down  the  pedicle,  rupture 
the  healthy  adhesions  established  in  the  wound,  or  by  repeated  dis- 
placements of  the  organs  produce  hsemorrhage  or  peritonitis.  This 
condition  is  fulfilled  by  covering  the  abdomen  with  cotton  wool  and  a 
bandage,  which  maintains  it  in  a  state  of  absolute  immobility  by 
moderate  but  methodic  compression.  It  is  also  fulfilled  by  the 
administration  of  opium  or  morphia.  Kceberle  is  in  the  habit  of 
giving  morphia  to  all  his  patients  after  operation.  In  England,  how- 
ever, narcotics  are  only  resorted  to  when  there  is  pain  or  sleeplessness. 
During  the  course  of  peritonitis  it  is  useful  to  empty  the  stomach  and 
to  wash  it  out  with  the  cesophageal  sound,  and  to  retard  organic 
fermentation  by  the  administration  of  sulphate  of  quinine  (Kceberle). 
Alcohol  and  opium  associated  with  anti-emetics  have  been  of  great 
service  to  me  in  these  circumstances. 

Lastly,  there  is  an  accident  which  it  is  important  to  prevent  or 
subdue,  that  is,  suppuration  of  the  wound  itself,  which  may  gradually 
produce  that  of  the  peritoneum  ;  the  accumulation  of  pus  is  not  long 
in  engendering  septicaemia  or  pygemia ;  suppuration  or  rather  putre- 
faction of  the  pedicle  mortified  by  constriction  is  sufBcient  by  contact 
or  absorption  to  produce  not  only  inflammation  of  the  peritoneum  but 
purulent  and  putrid  fever.  Hence  the  necessity  of  maintaining  great 
cleanliness  of  the  wound  by  dressings  repeated  three  times  a  day,  by  the 
frequent  change  of  lint,  by  removing  some  of  the  sutures  the  first  day, 
and  others  the  fourth  or  fifth  day  when  they  are  not  metallic,  by  laying 
little  bags  filled  with  absorbent  powders,  such  as  calcined  oyster  shells 
and  quinine,  rhubarb  and  chalk,  magnesia  and  cinnamon  (Spencer 
Wells),  on  the  parts  from  which  fluid  is  oozing  out;  lastly,  by  mum- 
mification of  the  pedicle  painted  with  caustic  perchloride  of  iron 
(Koiberle,  Keith,  Simpson),  and  even  by  irrigation  of  the  wound  and 
neighbouring  parts  which  threaten  to  become  inflamed  with  an  aqueous 
solution  of  sulphate  of  iron  (Kceberle). 

If  in  spite  of  these  precautions  pus  is  produced  in  the  pelvic  cavity, 
its  accumulation  should  be  prevented  either  by  the  introduction  of  a 
glass  tube  or  a  vulcanised  caoutchouc  drainage  tube  through  the  lower 
angle  of  the  wound  (Kojberle),  or  by  drainage  giving  exit  to  the  pus 
by  the  posterior  vaginal  cul-de-sac  ^  as  performed  by  Spencer  Wells, 

1  The  drainage  of  the  peritoneal  cavity  by  Douglas's  cul-de-sac  has  been 
practised  by  Peaslee  {Americ.  Journ.  of  Med.  Science,  1856,  1863  and  1864). 


768  UTEEINE    DISEASES   IN    DETAIL 

Koeberle,  or  Pean.  The  latter  surgeon  pierces  the  md-de-sac  twice 
from  within  outwards  by  means  of  a  trocar,  guided  by  the  finger 
passed  through  an  incision  made  above  the  crural  arch,  and  leaves  in 
it  an  india-rubber  tube,  the  loop  of  which^is  in  the  retro-uterine  cavity 
whilst  the  two  ends  hang  from  the  vagina.  As  a  rule,  however,  peri- 
toneo-vaginal  drainage  has  been  abandoned  for  peritoneo-abdominal 
drainage  which  is  rightly  considered  quite  as  useful  and  less  dangerous. 
T^ortunately  the  antiseptic  treatment,  i.e.  the  application  of  Lister's 
method  to  ovariotomy  (during  operation  as  well  as  in  the  dressings) 
by  diminishing  the  chances  of  septicaemia,  has  given  fresh  guarantees 
of  success  to  ovariotomy. 

To  sum  up,  the  dangerous  accidents  of  ovariotomy  seem  to  be  san- 
guineous oozing  into  the  peritoneum  and  the  accumulation  of  pus 
followed  by  septicaemia.  We  must  therefore  try  to  prevent  the  devel- 
opment of  these  accidents. 

Keith's  great  success  is  apparently  due  to  the  application  of  as 
many  hemostatic  ligatures  as  the  sanguineous  oozing  necessitates,  to 
peritoneo-abdominal  drainage  when  indicated,  and  to  the  use  of  Lis- 
terism,  both  preventive  and  consecutive,  other  circumstances  being 
seemingly  secondary  to  this  kind  of  therapeutic  tripod  on  which  the 
operative  success  of  ovariotomy  appears  to  rest.^  It  is  needless  to  add 
that  supposing  the  consequences  of  operation  have  been  benignant 
and  that  nothing  has  hindered  the  regular  course  towards  cure,  the 
quantity  of  food  administered  to  the  patient  ought  only  to  be  in- 
creased gradually,  and  the  permission  to  rise,  and  especially  to  walk, 
ought  to  be  delayed  as  long  as  possible,  for  it  should  always  be 
remembered  that  a  certain  time  is  required  to  give  to  recent  adhesions 
sufficient  firmness  to  enable  them  to  withstand  the  various  movements 
natural  to  women  in  normal  health. 

I  have  mentioned  the  itnpossihility  of  terminating  operation  as  one 
of  the  most  serious  accidents  of  ovariotomy.  This  danger  becomes 
less  frequent  every  day.  It  is  evident  that  if  adhesions  absolutely 
prevented  the  extraction  of  the  cyst  it  would  be  necessary  to  reunite 
the  lips  of  the  abdominal  wound  and  to  enclose  the  walls  of  the  cyst 
in  such  a  way  as  to  make  them  adhere  to  it,  either  by  trying  to  obtain 
the  obliteration  of  its  opening,  which  would  turn  the  operation  into 
one  of  simple  puncture,  or  by  leaving  the  orifice  of  the  cyst  open,  by 
enlarging  it  even,  and  so  preserving  the  possibility  of  introducing  into 
its  cavity  various  alterative  fluids  or  perchloride  of  iron,  which  would 
almost  reduce  the  operation  to  incision  of  the  cyst,  as  advised  by 
Ledran  and  performed  by  several  modern  surgeons,  but,  according  to 
Tock's  statistics,  not  very  successfully. 

Pean  has  brought  this  method  again  into  favour  by  his  success  in 
cases  where  he  could  not  complete  extraction  :  in  order  to  succeed,  it 
is  very  important  to  make  the  borders  of  the  cyst  adhere  exactly  to 

'  Mr.  Lawson  Tait  has  poibliahed  an  account  of  186  cases  of  abdominal 
section  he  has  performed  since  Nov.,  1879,  with  only  14  deaths.  _He  has  entirely 
abandoned  Lister's  antiseptic  treatment,  considering^  that  it  is  productive  of 
more  harm  than  good  (Paper  read  before  the  Birmingham  Branch  of  the  Brit. 
Med.  Assoc,  Nov.  11,  1880.— Med.  Times  and  Gazette,  Nov.  5,  1881.— Trans. 


OVARIAN    CYSTS 


769 


the  edges  of  the  abdomiDal  wound  and  to  prevent  all  communication 
with  the  peritoneal  cavity.  Before  these  surgical  improvements  exci- 
sion of  a  portion  of  the  cyst  had  only  given  poor  results/  therefore 
when  it  is  possible  we  should  try  to  reduce  the  operation,  by  the  exact 
union  of  the  wound,  to  the  conditions  of  a  simple  puncture. 

The  remote  consequences  of  ovariotomy  are  usually  as  satisfactory  as 
could  be  desired.  Patients  recover  perfectly,  perform  all  their  func- 
tions and  regain  flesh.  I  have  seen  some  who  had  been  operated  on 
ten  years  previously  and  who  had  been  in  perfect  health  ever  since. 
Nevertheless  painful  sensations  of  dragging  may  persist  for  some  time, 
due  to  the  slight  displacement  undergone  by  the  uterus,  to  the  adhe- 
sion of  the  pedicle  to  the  abdominal  wall  and  to  cicatrix  of  the 
ovarian  ligament.  I  have  seen  patients  in  whom,  owing  to  defective 
union  of  the  linea  alba  at  some  point  below  the  skin,  there  existed 
real  eventration  and  enterocele  of  the  linea  alba,  the  retention  of  which 
necessitated  the  use  of  a  belt  or  a  bandage  with  a  large  pad  similar  to 


Fig.  424. — Appearance  of  the  abdomen  with  cicatrix  three  weeks  after  extirpa- 
tion of  a  small  ovarian  cyst  without  adhesions  (after  Spencer  Wells). 

the  umbilical  bandage.  When  both  ovaries  have  been  removed  men- 
struation does  not  return  and  there  is  absolute  sterility ;  but  when  one 
only  has  been  extirpated,  menstruation  returns  after  operation,  resum- 
ing its  usual  course.  In  the  latter  case  conception  may  take  place 
and  be  followed  by  normal  pregnancy. 

'  See  Clay's  statistics  at  the  end  of  his  translation  of  Kiwisch. 

49 


770  UTERINE    DISEASES    IN    DETAIL 

More  than  twenty  of  Spencer  \Yells^s  '  patients,  three  of  Koeberle's, 
and  several  operated  on  by  other  surgeons  have  become  pregnant,  and 
each  time  the  pregnancy  has  terminated  normally;  the  first  patient 
operated  on  by  Koeberle  (June,  1863)  has  had  seven  children  since, 
two  of  which  were  twins.  A  woman  operated  on  by  Lane,  who  had 
had  an  abundant  suppuration  and  phlebitis  for  fifteen  days  previously, 
has  had  five  children  since. 

Lastly,  relapse,  i.e.  development  of  the  disease  in  the  other  ovary, 
lias  sometimes  been  observed.  Atlee,  Bird,  Spencer  Wells,  Boinet, 
Joiion  of  Nantes  have  had  to  extirpate  a  second  ovarian  cyst  some 
months  and  even  years  after  ablation  of  the  first  in  the  same  patient. 
Out  of  seven  operations  performed  on  the  second  ovary,  Spencer 
Wells  has  had  five  successes.  The  integrity  of  the  tissues  correspond- 
ing with  the  cicatrix  of  the  first  operation  was  ascertained,  no  trace  of 
the  latter  being  discovered  in  the  majority  of  cases.  Once  even,  as  I  have 
already  mentioned,  a  triple  ovariotomy  was  successfully  performed. 

Ylil.  Exiirj)atio7i  of  normal  ovaries. — This  operation,  which  is 
nothing  else  than  castration,  and  which  has  received  the  name  of 
Battet/'s  operation,  or  that  of  normal  ovariotomy,  has  been  performed 
so  often  on  various  occasions  that  there  can  be  no  doubt  as  to  the 
possibility  of  terminating  it  successfully,  and  of  saving  patients  in  a 
o-reat  number  of  cases.  In  1863  Kceberle  performed  this  operation 
and  recommended  simultaneous  extirpation  of  both  ovaries  and  of  the 
womb  in  cases  of  hysterectomy  or  supra-vaginal  amputation  of  the 
uterus  when  attacked  by  fibrous  tumours.  Nevertheless  till  1872  no 
gynsecologist  had  proposed  the  extraction  of  apparently  healthy  ovaries 
(or  castration)  with  the  sole  object  of  modifying  disorders  of  innerva- 
tion, the  starting-point  of  which  seemed  to  be  in  the  organs  them- 
selves. It  was  at  this  time  that  Battey  performed  what  he  calls 
normal  ovariotomy,  '^with  the  object,"  he  says,  "of  producing  an 
artificial  change  in  the  conditions  of  existence,  and  of  suppressing 
maladies  which  may  depend  on  them,  such  as  neuralgia,  dysmenor- 
rhoea,  hysteria,  mental  derangement,'"  &c.  According  to  this  surgeon 
the  indications  for  the  operation  are  :  "  1,  absence  of  the  uterus  and 
serious  permanent  disorders  caused  by  the  presence  of  the  ovaries; 
2,  obliteration  of  the  uterus  and  vagina  beyond  the  possibility  of 
restoration;  3,  the  exceptional  gravity  of  nervous,  hysteriform  and 
epileptiform  disorders  depending  on  an  ovarian  affection  and  resisting 
ail  ordinary  means  of  treatment;  4,  mental  and  physical  sufferings 
produced  by  congestion  of  the  ovaries  which  have  resisted  all  treat- 
ment" {Transact,  of  the  American  Gmiecol.  Soc,  1876).  In  1878 
Battey  had  performed  a  dozen  ovariotomies  (two  by  the  abdomen, 
the  others  by  the  vagina)  with  the  object  of  curing  obstinate 
nervous  affections;  in  four  cases  there  was  complete  cure,  in  six  cases 
the  result  was  nil,  in  the  remaining  two  the  patients  died. 

Another  indication  is  uncontrollable  metrorrhagia,  especially  dan- 
gerous catamenial  haemorrhage.     Hegar  of  Tribourg,  who,  in  1876, 

1  Gaz.  med.  de  Paris,  20  Oct.,  1869.  Since  then  the  number  of  these  cases 
Las  considerahly  increased. 


OVARIAN    CYSTS  771 

removed  the  ovaries  of  two  women  affected  in  this  way,  with  the  object 
of  arresting  the  loss  of  blood  and  of  putting  a  stop  to  the  congestion 
dependent  on  ovulation,  performed  the  operation  "by  the  abdomen  with 
short  ligatures,  and  had  the  satisfaction  of  saving  his  patients  after 
having  seen  them  pass  through  the  greatest  danger.  Sims,  out  of 
seven  operations  by  the  abdomen,  saved  six  patients;  but  out  of 
four  operations  by  the  vagina  for  dysmenorrhoeic  ovarialgia,  he  lost 
all   [Bid.  de  med.  et  de  cJiir.,  art.  Ovaire). 

If  the  efficacy  of  castration  in  the  case  of  nervous  affections  is 
problematical,  there  is  hardly  any  doubt  as  to  the  services  this 
operation  might  render  by  bringing  on  the  menopause  prema- 
turely in  women  affected  with  dangerous  hsemorrhage.  This  is  the 
opinion  of  Sims,  Hegar,  and  of  several  others  {Medical  Times  and 
Gazette,  1877).  Goodell  [American  Journal,  July,  1878)  also  per- 
formed castration  for  a  large  posterior  fibroma  with  symptomatic 
menorrhagia ;  after  eight  months  the  hsemorrhage  had  ceased,  the 
tumour  had  diminished  to  less  than  half  its  size,  and  the  patient^'s 
health  was  excellent.  Exceptionally,  menstruation  has  continued  after 
castration.  Goodell  mentions  two  cases  of  double  normal  ovariotomy 
in  which  a  more  or  less  regular  and  abundant  discharge  of  blood  like 
menstruation  continued  afterwards;  but  in  seventy-eight  other  cases  or" 
ablation  of  both  ovaries  collected  by  the  same  writer  menstruation  was 
completely  suspended.  Unfortunately  the  operation,  serious  as  it  is  by 
the  abdomen,  is  still  more  so  by  the  vagina  on  account  of  the  adhe- 
sions and  variations  in  the  size  and  position  of  the  ovaries,  which  have 
always  suffered  from  inflammatory  or  other  maladies  when  operation  is 
indicated,  and  which  are  therefore  far  from  being  in  the  favorable  con- 
ditions in  which  the  same  organs  are  when  they  have  never  been 
diseased.  Goodell  rejects  Battey's  expression  of  normal  ovariotomy, 
preferring  that  of  castration.  Trenholme  had  a  case  [Obstet.  Journ,, 
Oct.,  1876)  in  which  both  ovaries  were  removed  and  the  pedicles  left 
in  the  abdomen,  with  the  object  of  diminishing  uterine  fibroids,  by 
taking  from  them  their  means  of  existence  by  the  suppression  of  erec- 
tion and  of  the  monthly  ovarian  congestion  which  react  on  the  whole 
genital  economy.  It  is  certainly  very  problematical;  nevertheless  two 
cases  of  Hegar's  and  one  of  Nussbaum's  seem  to  justify  the  idea. 
Goodell  also  has  performed  it  with  the  same  object  and  operates  in 
the  following  way.  The  vagina  is  depressed  by  a  Sims^s  speculum 
whilst  a  fold  of  the  mucous  membrane  is  seized  by  a  tenaculum  hook 
behind  the  cervix.  An  incision  of  4  centimetres  is  made  there  with 
Kiichenmeister's  scissors;  the  peritoneum  is  then  divided  and  the 
index  finger  of  the  left  hand  being  introduced,  it  follows  the  course  of 
the  l^allopian  tube,  hooks  the  two  ovaries  successively,  seizes  them 
with  a  pair  of  fenestrated  forceps  and  brings  them  into  the  vagina 
where  they  are  hgatured  and  excised.  Their  pedicles  are  firmly  liga- 
tured with  antiseptic  silk  and  replaced  in  the  pelvic  cavity.  There  is 
little  haemorrhage  and  no  suture  in  the  vaginal  wound.  In  Goodell^s 
operation  which  I  have  just  mentioned  the  fibroid  was  discovered  with 
great  difficulty  six  months  afterwards,  although  previously  it  had  been 


772  UTERINE    DISEASES    IN    DETAIL 

very  painful  and  had  formed  one  body  with  the  uterus  in  acute  anti- 
flexion.  As  for  the  other  cases  of  dangerous  hsemorrhage  and  of 
nervous,  organic  or  psychical  symptoms  which  have  withstood  all 
means  of  treatment,  I  do  not  see  any  formal  contraindication.  Opera- 
tion may  also  be  indicated  when  the  life  of  the  patient  is  endangered 
by  a  malady  which  no  other  treatment  can  cure.  In  spite,  however, 
of  the  advantage  presented  by  operation  by  the  vagina,  if  we  were 
certain  of  finding  the  organs  in  normal  condition,  the  absence  of  certi- 
tude is  a  sufficient  reason  for  preferring  operation  by  the  abdomen. 

IX.  Mxtirpation  of  fibrous  tumours  and  of  the  uterushy  gastrotomy. 
— Gastrotomy  has  also  been  applied  to  the  ablation  of  large  uterine 
sub-peritoneal  myomata,  either  in  consequence  of  an  error  of  diagnosis 
which  led  to  the  discovery  of  a  fibrous  tumour  in  place  of  the  ovarian 
cyst  which  was  expected,  or  else  from  the  express  desire  to  apply  the 
radical  cure  of  the  latter  malady  in  the  treatment  of  the  former.  The 
first  attempt  at  extirpation  of  the  uterus  and  of  peritoneal  fibromata 
was  made  by  Heath  (of  Manchester)  in  1843,  in  consequence  of  an 
error  of  diagnosis ;  he  thought  he  had  a  case  of  ovarian  cyst ;  the 
patient  died.  The  first  successful  operations  were  performed  by  two 
American  surgeons,  Barnham  in  1853,  and  Kimball  in  1855.  Some 
years  ago.  Clay  (of  Manchester),  believing  that  he  had  to  do  with  a 
multilocular  cyst  and  discovering  instead  uterine  fibrous  tumours, 
removed  the  uterus,  or  at  least  the  fundus  of  the  organ  with  the 
tumours,  ovaries  and  Fallopian  tube,  after  having  applied  a  strong 
ligature  to  the  cervix  immediately  above  the  vaginal  insertion  which 
he  retained  in  the  inferior  angle  of  the  wound  till  it  fell :  the  patient 
was  cured.  The  fibroids  with  the  portion  of  uterus  and  the  ovaries 
weighed  eight  pounds ;  the  anatomical  preparation  is  in  Edinburgh.^ 
About  the  same  time  Koeberle  successfully  extirpated  a  uterine  fibroid 
and  the  two  ovaries,  also  amputating  the  whole  of  the  supra- 
vaginal portion  of  the  womb.^  This  operation  which  at  first  was  called 
liysterotomy  has  sioce  received  the  more  correct  name  of  hysterectomy, 
since  it  is  a  question  of  extirpating  and  not  only  of  dividing  the  uterus. 
In  my  opinion  we  do  not  yet  possess  a  sufficient  number  of  cases  to 
authorise  our  forming  a  judgment  as  to  the  justifiabiHty  of  the  opera- 
tion,3  but  I  must  admit  that  the  number  of  successful  cases  seems  to 
increase  in  proportion  to  the  number  of  operations  performed  and  with 
improved  methods.  Amongst  the  encouraging  cases  I  may  mention 
that  of  Storer  (of  Boston)  quoted  by  Koeberle  which  was  followed  by 
cure  ;  one  of  Spencer  Wells's,^  in  which  the  fibroma  was  separated  from 
the  fundus  of  the  uterus  by  linear  ecrasement,  haemorrhage  was 
arrested  by  ligature  and  the  point  of  section  of  the  womb  was  retained 
in  the  lower  angle  of  the  wound ;  the  patient  recovered  ;  that  of  Tran- 
holme  in  which  there  was  ablation  of  the  uterus  and  both  ovaries  for  a 
fibro-cystic  tumour  in  a  negress  of  about  40,  who  recovered  and  soon 

1  London  Med.  Gaz.,  18  April,  1863. 

2  Communication  to  the  Acad,  des  Sciences,  15  June,  1863. 

^  Pozzi,  Valeur  de  I'hysterotomie  dans  le  traitement  des  tumeurs  fibreuses 
de  I'lderus.     Paris,  1875. 
*  Med.  Times,  1871. 


OVAEIAN    CYSTS  773 

afterwards  resumed  marital  intercourse  [Ha^/etn Revue,  t.  v,pp.  1 79,  761); 
Tillaux's  case  [Annates  de  Gynecol.,  1879,  t.  xii,  p.  118)  of  uterine 
fibroma  in  the  left  lateral  wall  with  dangerous  hsemorrhage,  unbearable 
pain,  intestinal  occlusion  from  compression,  extirpation  and  success  \ 
Kimball's  successful  case  {Annales  de  Gynecol,  t.  ix,  p.  61),  which 
however  did  not  prevent  the  operator  from  condemning  hysterectomy 
at  the  Congress  of  Chicago  in  1877;  a  number  of  other  cases  might 
be  mentioned. 

There  can  however  be  no  doubt  that  hysterectomy  is  more  dangerous 
than  ovariotomy.  Koeberle  [Diet,  de  med.  et  chir.  prat.,  art.  Ovaire, 
t.  XXV,  p.  594),  out  of  20  cases  of  hysterectomy  performed  by 
himself,  counts  10  deaths  and  ]0  cures.  Terrier  has  performed 
hysterectomy  twice  and  has  lost  both  patients.  Pean  has  performed 
the  operation  43  times,  has  had  33  successful  cases,  and  10  deaths 
(oral  communication).  These  are,  I  think,  the  most  favorable 
statistics  known,  and  they  are  not  very  encouraging.  These 
cases  do  not  include  operations  performed  for  cancer :  they  may  be 
analysed  thus :  hysterectomy  has  been  performed  by  Pean  35 
times  for  fibromata  (22  cures,  13  deaths),  of  this  number  one 
was  complicated  with  an  ovarian  cyst,  another  with  a  cyst  of  the 
broad  ligament;  once  for  hypertrophy  complicated  with  pelvic 
cyst  (cure) ;  eight  times  for  fibro-cystic  tumours  (5  cures,  3 
deaths)  ;  four  times  for  uterine -cystic  tumours  (4  cures)  ;  once  for 
hypertrophy  from  sarcomatous  degeneration  of  the  mucous  membrane 
and  retention  (cure).^  Whilst  admitting  that  hysterectomy  may 
be  resorted  to  when  nothing  can  be  expected  from  any  other  treatment, 
we  should  be  all  the  more  disposed  to  delay  decision  if  the  tumour 
does  not  progress  rapidly,  as  experience  has  proved  the  occasional 
efiicacy  of  the  continuous  current,  ergotine,  hot  injections,  resolvent 
alteratives  and  other  means  in  arresting  the  development  and  even  in 
producing  diminution  of  these  tumours.  We  shall  therefore  limit  the 
indications  to  the  following  cases  :  danger  from  haemorrhage,  threaten- 
ing of  rapid  and  enormous  development  of  the  tumour,  compression 
of  the  ureters,  which  has  caused  death  (Matthews  Duncan,  Brit.  Med. 
Journ.,  29th  April,  1877),  fibroma  of  the  posterior  wall  wedged 
tightly  into  the  pelvis  causing  constipation  and  threatening  death. 

X.  Puerperal  hysterectomy  of  Porro.  —  Laparo-etytrotomy  of 
Thomas. — Ovariotomy  has  so  familiarised  surgeons  with  opening  the 
peritoneum,  and  hysterotomy  for  fibroids  has  so  frequently  led  gyneco- 
logists to  consider  the  best  manner  of  reaching  the  uterus  either  to 
open  it  or  to  excise  a  more  or  less  considerable  portion  of  it,  that  they 
have  led  to  the  practice  of  Caesarian  section,  i.e.  hysterotomy  in  the 
puerperal  state,  and  to  the  invention  of  new  methods  with  the  object  of 
facilitating  extraction  of  tlie  foetus  and  of  saving  the  life  of  the  mother. 
I  shall  merely  say  a  few  words  about  these  operations  which  belong 
exclusively  to  obstetrics. 

1  Pean  and  Urdy,  De  Vahlation  partielle  ou  totalc  de  I'uterus  par  la  gas- 
trotomie.  Paris,  1873. — Diagnostic  et  traitement  des  tumours  de  I'abdomen  et 
du  hassin.  Paris,  1880. 


774  UTERINE    DISEASES   IN    DETAIL 

The  idea  was  conceived  of  performing  amputation  of  the  uterus  after 
C<Bsarian  section  ;  it  had  been  applied  to  animals  and  the  operation  was 
afterwards  performed  on  a  woman  by  Storer  in  1860;  unfortunately 
the  patient  died.  In  1876  Porro^  ignorant  of  the  case,  being  obliged 
to  perform  Caesarian  section  and  having  delivered  a  healthy  child,  ampu- 
tated the  uterus  and  its  appendages  immediately  afterwards,  employing 
igorous  antiseptic  treatment.  In  spite  of  numerous  cases  of  puer- 
peral fever  then  reigning  at  the  Maternity  Hospital  of  Pavia  the  patient 
recovered  and  left  the  hospital  with  her  child  the  fortieth  day  after 
>peration.  We  must  admit  that  the  judgment  which  attributed  the 
subsequent  dangers  of  Caesarian  section  to  the  presence  of  the  wounded 
uterus  and  which  regarded  extirpation  of  this  organ  as  the  radical 
remedy  of  the  evil  was  correct,  and  that  the  conditions  of  success  were 
to  be  found  in  the  performance  of  the  operation  assisted  by  antiseptic 
treatment.  Since  then,  out  of  83  patients  who  have  undergone  Porro^'s 
operation  in  maternity  hospitals,  15  have  died,  18  have  been  cured, 
and  the  majority  of  the  children  have  been  saved,  a  far  more  favor- 
able result  than  had  ever  been  attained  by  the  ancient  method  of 
Caesarian  section  (Pinard,  De  V operation  cesarienne  suivie  de  V ampu- 
tation utero-ovarique  ou  operation  de  Porro.  Annates  de  Gynecol., 
1879.     Masson,  I)e  la  g astro-Sly trotomie.     Theses  de  Paris,  1877). 

The  laparo-elytrotomy  of  Gaillard  Thomas  is  a  lateral  incision  from 
the  spine  of  the  pubis  to  the  antero-posterior  iliac  spine  parallel  to 
and  above  the  crural  arch,  through  which  the  vagina  is  opened  at  its 
junction  with  the  uterus,  so  as  to  allow  of  extracting  the  child  from 
it  in  place  of  extracting  it  from  the  fundus  of  the  uterus  through  the 
linea  alba  which  constitutes  Caesarian  section.  Gaillard  Thomas  com- 
municated this  method  to  the  Academy  of  Medicine  of  New  York 
on  the  21st  March,  1878  ;  out  of  five  operations  he  had  saved  four 
children  and  three  mothers  (^Annates  de  Gynecol.,  t.  x,  p.  232). 
Lateral  incision  is  necessary  here,  laparotomy  meaning  lumbar  incision, 
which  was  resorted  to  in  the  first  ovariotomy ;  afterwards,  however, 
MacDowell  adopted  the  central  line, 

2.  Tumours  of  the  Annexes  and  Pelcic  Cavity. 

According  to  Leopold  (Arc/iiv  f.  Gyn.,  Bd.  vi,  2)  solid  tumours  of 
the  ovai'ies  are  rare,  in  the  proportion  of  1*5  per  cent,  of  liquid 
tumours  or  cysts.  They  retain  the  normal  shape  of  the  organ  by 
which  they  are  distinguished  from  cysts.  They  have  a  variable  con- 
sistency, from  that  of  false  fluctuation  to  that  of  stony  hardness.  Their 
exterior  wall  has  also  a  variable  thickness.  The  pedicle  is  usually 
short,  and  although  the  tumour  may  be  closely  attached  to  the  uterus 
the  latter  remains  normal.  Among  these  tumours  we  may  distinguish  : 
1.  Fibromata,  simple  or  complex  (fibro-myomata,  fibro-sarcomata),  or 
with  sanguineous  lacunary  spaces  interposed  (Waldeyer),  or  presenting 
an  analogy  with  certain  osteoid  tumours,  i.e.  points  of  ossification;^ 
there  are  also  areolar  fibromata  (Spiegelberg),  presenting  a  frame- 

^  Koplierle  does  not  believe  in  fibro-myoma  of  the  ovanes  {Diet,  de  med. 
et  de  cMr.W'cdiq.,  art.  Ovaiees,  t.  xxv,  p.  508).  I  have  undoubtedly  seen  tliem. 


PELVIC    TUMOURS  775 

work  of  fusiform  cells  with  a  cavernous  vascular  development  like 
that  of  sarcoma.  2.  Enchondromata  (exceptional),  which  must  not 
be  confounded  with  fibromata  of  cartilaginous  consistency.  3.  Sarco- 
mata (rare),  the  blood-vessels  of  which  are  numerous  and  small  in 
little  tumours,  but  in  large  tumours,  on  the  contrary,  are  very  much 
dilated,  have  a  thin  wall  without  any  muscular  tunic  or  tunica  adven- 
titia,  and  furnished  with  simple  endothelium.  4.  Carcinoma,  which 
I  shall  afterwards  describe.  5.  Cystomatous  lymphangiomata  have 
also  been  seen  in  the  ovary  (cysts  remarkable  for  the  dilatation  of  the 
lymphatics  and  the  proliferation  of  the  stroma). 

Ziembicki  [Essai  cUnique  stir  les  tumeurs  solides  des  ovaires.  Theses 
de  Paris,  1875)  has  collected  38  cases  (11  of  sarcoma,  10  of  fibroma, 
6  of  carcinoma,  3  of  colloid  tumours,  5  of  cystic  adenoma,  3  undeter- 
mmed),  the  result  of  which  is  that  solid  ovarian  tumours  are  more  apt 
to  be  met  with  in  young  women.  The  peripheric  vessels  were  very 
large  in  five  cases  only_.  We  know,  however,  that  very  small  tumours, 
a  hematic  cyst  of  the  right  ovary  for  example  of  the  size  of  a  chest- 
nut, may  cause  intra-peritoneal  haemorrhage  ending  in  death  in  thirty- 
six  hours  (Curt  Wallis  and  Linden,  Hi/geia,  1876;  Hayem,  Revue,  t. 
ix,  p.  623).  As  a  rule  ovaries  attacked  by  these  tumours  have  few  or 
no  adhesions.  Ascites  is  common  without  peritonitis  or  vascular  com- 
pression; it  is  a  serious  sign  when  the  tumour  occupies  the  iliac  fossa, 
which  it  usually  does.  The  writer  has  divided  them  into  three  groups  : 
one  including  tumours  of  rapid  formation  developed  in  from  three 
months  to  two  years  (carcinoma,  sarcoma) ;  another,  tumours  of  slow 
formation  of  from  two  to  ten  years  (fibromata,  dermoid  cysts,  cysts 
with  thick  contents) ;  and  another  rare  form  in  which  ascites  is 
absent,  and  the  economy  does  not  seem  to  be  disturbed,  although  this 
is  of  tlie  worst  kind.  We  must  beware  of  making  an  exploratory 
puncture  in  such  cases,  it  being  better  to  perform  ovariotomy  early. 
In  these  cases,  however,  success  is  not  common  :  out  of  eight  opera- 
tions mentioned  by  Leopold  only  three  were  successful.  Menstruation 
may  continue  in  spite  of  the  most  serious  degeneration  of  both  ovaries  ; 
conception  and  pregnancy  may  even  occur  (Treille,  Tameurs  de  Vovaire 
dans  leurs  rapports  avec  robstetriqiie,  c'est-a-dire  avec  la  conception, 
la  grossesse,  U accouchemerit,  la  puerjoeralite.  Theses  de  Paris,  1873). 
Yernich  thinks  that  an  ovarian  tumour  may  become  malignant  through 
pregnancy  and  the  puerperal  state.  He  mentions  the  case  of  a  young 
woman  attacked  by  a  tumour  which  for  a  long  time  was  painless, 
but  which  increased  during  pregnancy,  and  at  the  autopsy  proved  to 
be  a  medullary  carcinoma  {Du  pronosttc  des  tumeurs  ovariqnes  com- 
pliquant  la  grossesse.  Beitraege  zur  Geburtsk.  und  Gynecol.,  Bd. 
ii,  2).  Hempel  {drc/dv  f.  Gynecol.,  Bd.  vii,  3,  1875)  mentions  a 
case  of  carcinomatous  degeneration  of  both  ovaries  during  pregnancy. 
Several  analogous  cases  have  been  published  by  Braxton  llicks^ 
Kiirsteiner,  Spencer  Wells,  Ilecker,  Buhl,  Hempel,  Wallis, 
Linden,  &c. 

I.  Malignant  tumours  of  the  ovaries. — These  are  nothing  but  cancer 
under  various    forms.      Whether    classed   as   sciirhus,   encc])haloid. 


776 


UTEEINE    DISEASES   IN    DETAIL 


ceplialoma,  hematoma,  fungus  hematoides,  fibro-medullary  carcinoma, 
cysto-carcinoma,  melanic  cancer,  &c.,  they  have  all  the  aggressive, 
destructive  and  cachectic  tendency  wliich  characterises  cancer.  How- 
ever, the  various  forms  which  these  names  recall  may  be  met  with  in 
the  different  cases  of  cancer  of  the  ovaries;  this  organic  alteration  may 
be  combined  with  the  existence  of  colloid  or  gelatinous  matter,  with 
the  so-called  areolar  degeneration,  as  well  as  with  the  production  of 
fibroids,  or  the  development  of  cysts  whether  follicular  or  interstitial. 


Fig.  425. — Colloid  cancer  of  the  ovary  (Cruveilhier).  The  uterus  and  Fallo- 
pian tube  remaining  attached  to  the  tumour  by  the  ligament  of  the 
diseased  ovary,  we  may  form  an  idea  of  the  enormous  development  of  this 
tumour. 

i.e.  vesicular  dropsies  or  cystoids.  These  morbid  associations  and  the 
varieties  which  they  engender  depend  on  the  real  identity  which  cancer 
may  present  under  these  various  appearances,  and  on  the  natural  ten- 
dencies which  the  development  of  the  degenerated  tissue  brings  into 
play  in  an  organ  so  disposed  to  hypertrophy  in  the  form  of  fibromata 
or  cysts.  Cancer  of  the  ovary  seems  to  present  itself  more  frequently 
under  the  form  of  encephaloid  than  of  any  other  tissue.^  It  may- 
attain  considerable  dimensions.  I  have  lately  seen  one  occupying  the 
right  ovary,  weighing  more  than  11  lbs.,  forming  a  globular  nodu- 
lated mass  with  very  distinct  spheroidal  projections,  of  considerable 
size  and  occupying  the  whole  of  the  right  iliac  and  hypogastric 
regions,  associated  with  integrity  of  the  tube,  congestive  hypertrophy 
of  the  uterus  and  the  recurrence  of  haemorrhage  simulating  menstrua- 
tion in  a  woman  who  had  passed  the  menopause.  The  encephaloid 
masses,  diffluent  at  several  points,  appeared  to  have  originated  in 
Graafian  vesicles  they  were  so  well  encysted;  they  seemed  even,  in 
several  of  these  cysts,  to  have  vegetated  on  the  internal  membrane  of 
the  vesicle,  preserving  an  areolar  or  alveolar  aspect,  whilst  the  centre 
^  Lebert,  op.  cit.,  p.  323. 


PELVIC    TUMOURS  777 

was  filled  with  fluid  and  especially  with  blood  ;  several  of  these  cysts 
were  distended  by  black  blood,  partly  coagulated,  apparently  poured 
out  by  internal  hsemorrhages,  analogous  to  those  which  endanger  the 
life  of  patients  in  cases  of  external  encephaloid ;  lastly,  in  several  cysts 
was  to  be  seen  yellow  matter  similar  not  only  to  that  which  is  some- 
times met  with  in  cancer,  but  also  to  that  of  a  corpus  luteum,  situated 
in  a  superficial  portion  of  the  sac,  and  suggesting  the  idea  that  the  ence- 
phaloid had  been  developed  in  ruptured  Graafian  vesicles  and  in  the 
midst  of  true  degenerated  corpora  lutea,  an  alteration  mentioned  by 
Rokitansky ;  in  others,  black  pigment  was  seen  accumulated  against 
the  wall  of  the  cyst  between  its  internal  membrane  and  the  encepha- 
loid tissue  occupying  the  cavity  of  the  chamber. 

The  signs  of  ovarian  cancer  are  those  of  all  ovarian  tumours,  especi- 
ally of  cysts ;  but  there  are  other  differential  signs.  They  are :  the 
more  advanced  age  at  which  it  is  usually  manifested  (after  40  and 
even  50),^  the  rapidity  of  its  development  and  course  (patients 
usually  succumb  within  the  year),  the  nodulated  form,  the  smaller 
size,  the  hardness  and  sensitiveness  of  the  tumour,  the  pains  (?)  experi- 
enced by  the  patient,  the  symptoms  of  internal  or  intra-cystic  haemor- 
rhage which  may  occur,  the  premature  disturbance  of  the  functions 
and  of  the  general  health,  oedema  of  the  lower  limbs,  ascites  (which 
may  conceal  the  evil,  but  the  evacuation  of  which  by  puncture  allows 
of  a  most  certain  diagnosis  and  procures  temporary  alleviation  to 
the  patient),  lastly,  the  engorgement  of  the  mesenteric  ganglia,  the 
earthy  look  of  the  skin,  the  straw  or  leaden-coloured  complexion, 
hectic  fever  and  the  signs  of  cachexia. 

Treatment  is  merely  palliative.  Attention  to  hygiene,  plenty  of 
good  air  and  milk,  associated  with  tonics,  preparations  of  iron,  arsenic, 
hemlock  j  narcotics,  sedatives  by  the  rectum  or  skin ;  abdominal  para- 
centesis to  evacuate  the  fluid  accumulated  in  the  peritoneum,  repeated 
as  frequently  as  may  be  necessary ;  these  are  the  means  to  be  em- 
ployed. 

II.  Avulsion  and  transmutation  of  the  degenerated  ovary. — What- 
ever difficulty  there  may  be  in  diagnosing  this  malady  in  practice,  it 
is  well  to  know  that  the  ovary  sometimes  contracts  such  adhesions 
with  the  pelvic  walls  or  abdominal  viscera  that  the  dragging  produced 
by  the  subsequent  development  of  these  viscera  or  of  the  uterus  may 
lacerate  its  natural  attachments  rather  than  its  abnormal  adhesions. 
Eokitansky^  published  seven  cases  of  this  very  rare  pathological  fact. 
In  all  of  them  the  ovary  was  degenerated  :  three  times  into  a  cyst  filled 
with  fat ;  twice  into  osteo-calcareous  tissue ;  once  into  a  sac  filled  with 
blood ;  once  into  a  sac  containing  fatty  and  calcareous  matter.  In  all 
the  cases  except  one  avulsion  had  occurred  in  the  left  ovary.  In  all 
the  displaced  ovary  adhered  either  to  Douglas's  cul-de-sac,  to  the  sig- 
moid flexure  or  to  the  pubis,  rectum,  epiploon,  mesentery,  or  abdomi- 

^  Bucquoy  {Soc.  med.  cles  Hopitaux,  Dec,  18G6),  quotod  by  Mauriac  iu  his 
translation  of  West. 

2  Momoire  sior  I' arrachement  des  trompes  et  des  ovaires,  &c.  {Allgemeine 
Wiener  medizinische  Zeitun<j,  ISIO,  Nos.  2 — 4). 


778  UTERINE    DISEASES    IX  . DETAIL 

nal  wall^  the  adhesions  being  the  last  traces  of  circamscribed  peritoni- 
tis. In  cases  of  intestinal  adhesions  laceration  appeared  to  be  caused 
by  the  dragging  resulting  from  the  alternations  of  distension  and 
vacuity^  and  from  the  peristaltic  and  antiperistaltic  movements  of  the 
intestine.  In  two  other  cases^  originating  probably  in  childhood,  the 
cause  of  avulsion  was  undoubtedly  the  physiological  development  of 
the  uterus,  and  in  two  others  gestatory  hypertrophy.  In  one  case 
there  was  strangulation  of  the  Pallopian  tube  and  ovary  from  twisting 
round  their  axis. 

Turner^  found  in  the  necropsy  of  a  woman  of  75  a  tumour  of  the  size 
of  a  foetal  head  firmly  adherent  to  the  peritoneum  on  a  level  with  the 
sacro-vertebral  angle,  rising  above  the  brim,  fixed  by  adhesions  and 
presenting  all  the  characters  of  an  ovarian  cyst.  It  appeared  that  the 
uterus  had  been  united  to  the  floor  and  to  the  left  wall  of  the  pelvis 
by  long-standing  perimetritis.  The  left  ovary,  increasing  in  size  in 
consequence  of  its  cystic  degeneration,  had  probably  risen  gradually 
out  of  the  pelvis,  dragging  the  Pallopian  tube  and  broad  ligament  to 
the  left  side.  These  organs  not  having  been  able  to  yield  more  on 
account  of  the  uterine  adhesions  and  of  the  contraction  of  these  adhe- 
sions, had  become  atrophied,  and  finally  the  left  ovary  had  separated 
from  the  uterus. 

III.  Tubal  tumours. — I  have  already  spoken  of  several  maladies 
which  may  produce  general  or  partial  increase  of  size  and  even  a 
solution  of  continuity  of  the  tubes :  inflammation,  catarrh,  circum- 
scribed obliterations,  the  accumulation  of  mucus,  of  epithelial  ele- 
ments, suppuration,  abscesses,  haemorrhages,  with  free  discharge  or 
retention  of  blood  and  pus,  with  peripheric  adhesions,  dilatation  or 
ruptures  of  the  oviducts,  fibroids,  tubercle,  &c.  Cancer  is  rarely  seen 
in  the  tubes.  It  is  more  apt  to  appear  there  as  an  extension  of 
uterine  cancer  than  of  cancer  of  the  ovaries ;  for  the  Pallopian  tube 
may  be  seen  in  a  healthy  state  lying  on  the  diseased  ovary,  contrasting 
by  its  small  size  and  integrity  with  the  enormous  tumefaction  and 
serious  degeneration  of  the  germinative  organ.  The  only  tumours 
which  yet  remain  to  be  described  are  tubal  dilatations,  due  either  to 
excessive  or  disordered  mucous  secretion,  usually  coinciding  with 
contraction  or  atresia  of  their  canal,  either  from  a  cyst  developed 
within  their  walls,  in  their  neighbourhood,  or  even  in  the  cor- 
responding ovary,  and  possibly  communicating  with  the  enlarged 
cavity. 

1.  When  there  is  tubal  dropsi/,  i.e.  dilatation  of  these  organs  by 
the  accumulation  of  a  sero-sanguinolent  fluid  or  of  a  mass  of  cells  or 
debris  of  epithelium  which  may  have  been  taken  for  tuberculous 
matter,  the  malady  may  appear  under  various  aspects.  Sometimes 
only  one  tube  is  aft'ected,  sometimes  both  organs  are  attacked  almost 
equally  and  symmetrically.  Earely  the  diseased  oviduct  is  free  and 
presents  no  alteration  at  its  periphery :  usually  it  bears  traces  of  pre- 
vious inflammation,  and  is  connected  with  the  neighbouring  parts, 
with  the  posterior  surface  of  the  uterus  or  ovary  by  pseudo-mem- 
^  Edinburgh  Medical  Journal,  1861. 


PELVIC    TUMOUES 


779 


brauous  adhesions  wliicli  deprive  it  of  all  mobility.  The  disorder 
may  extend  the  whole  length  of  the  tube^  but  more  frequently  it  is 
limited  to  one  half  of  this  canal :  the  portion  which  appears  the  most 
prone  to  disease,  the  one  in  which  the  mucus  accumulates  in  greatest 
quantity  and  the  distension  of  which  is  most  frequent  and  most  con- 
siderable is  the  external  or  ovarian  half.  When  the  whole  tube,  or 
half  of  it,  is  dilated  by  the  uniform  accumulation  of  fluid,  the  organ 
in  spite  of  its  dilatation  preserves  to  some  extent  its  normal  form  and 
presents  the  appearance  of  a  portion  of  the  intestine  with  somewhat 
incomplete  circumvolutions,  unequally  distended  by  its  contents; 
when  on  the  contrary  the  dilatation  is  limited  by  neighbouring  oblite- 
rations, or  by  the  resistance  of  a  cystic  envelope  in  which  the  fluid 


Fig.  426. — Falloxjian  tubes  distended  in  tiieir  external  or  ovarian  portion  by  a, 
fluid  collection,  and  a  small  cyst  attached  to  one  of  tbe  tubes  (Hooper). 

which  occasions  the  distension  is  contained,  the  tumour  is  circum- 
scribed and  globular,  and  the  rest  of  the  organ,  hardly  exceeding  its 
normal  size,  is  neither  perceptible  to  touch  nor  to  sight.  I  have 
sometimes  seen  tumours  like  those  I  have  just  described  and  similar 
to  those  mentioned  by  De  Haen,^  Monro,-  Boivin  and  Duges,^ 
Kiwisch,*  Becquerel,^  Scanzoni,''  Rokitansky,'^  Klob,^  &c. 

^  Pract.  Med.,  iii,  313. 

^  An  Essay  on  Dropsy.  London,  1765. 

3  Op.  cit.,  ii,  590.  Atlas,  pi.  xx.w,  fig.  1. 

''  Klinik.  Wortrdg.,  ii,  202.  Prague,  1849. 

«  Op.  cit.,  t.ii,  p.  278. 

«  Op.  cit.,  p.  371. 

'  Lchrhuch  dcr  imtliol.  Anat..  iii,  410.  Vienna.  1861. 

*  Path.  Anat.  der  ivelb.  Scijualorgaacn,  p.  288.  Vienna,  1864. 


780  UTEEINE    DISEASES    IN    DETAIL 

It  is  evident  that  there  are  no  other  elements  for  diagnosis  than 
those  which  I  have  already  described  in  speaking  of  salpingitis  and 
tubal  abscesses ;  and  there  is  no  doubt  that  the  difficulties  of  diagnosis 
have  frequently  led  to  tubal  cysts  being  taken  for  ovarian  tumours.^ 

2.  The  existence  of  Mo-ovarian  cysts  is  established  by  five  very 
interesting  cases  described  by  Adolphe  Eichard/  and  by  others 
already  quoted  by  Morgagni,  Franck,  Chambon,  Boivin  and  Duges, 
Kiwisch,  Follin,  &c.  It  is  proved  by  these  cases  that  ovarian  cysts 
may  open  into  the  uterus  by  the  medium  of  the  tube ;  that  after  having 
received  the  cystic  fluid  the  Fallopian  tube  continues  to  undergo  patho- 
logical change  ;  that  its  calibre  increases,  its  length  doubles,  its  walls 
thicken,  and  the  folds  of  its  mucous  membrane  partly  disappear; 
that  the  dilatation  gradually  reaches  the  internal  portion  of  the  oviduct, 
that  a  communication  is  established  between  the  canal  of  the  dilated  tube 
and  the  cyst,  and  that  from  that  time  the  complex  cyst  is  formed,  rightly 
designated  as  tubo-ovarian  by  Eichard,  which  is  probably  somewhat 
allied  to  the  malady  described  by  Eokitansky  under  the  name  of 
projluent  dropsy  of  the  tubes.  It  is  in  cases  of  this  kind  that  cathe- 
terism  of  the  tubes  may  be  performed.  Although  in  normal  conditions 
tubal  catheterism  is  absolutely  impossible,  nevertheless  in  cases  of 
menstrual  retention  or  of  dragging  upon  the  tube  by  a  fibroma  above 
and  in  the  axis  of  the  uterus  or  of  profluent  tubal  dropsy,  the  sound 
can  really  be  passed  from  the  uterus  into  the  tube.  This  penetration, 
seen  by  Biedert  and  others,  has  been  verified  at  an  autopsy  made  by 
Bischoff  (Hayem,  Revue  des  sciences  med.,  1878,  t.  xi,  p.  583).  This 
malady  or  a  tubal  abscess  is  apt  to  be  confounded  with  a  purulent  col- 
lection, circumscribed  by  peritoneal  adhesions  round  the  ovary  and 
tube,  and  evacuated  directly  by  the  genital  canal  through  the  medium 
of  the  oviduct,  a  disease  which  was  once  seen  by  Kceberle  (Nouv. 
Diet,  de  med.  et  de  chir.  prat.,  art.  Ovaire,  t.  xxv,  p.  500,  fig. 
Paris,  1878. 

It  is  not  possible  to  give  any  rule  of  treatment  for  these  cysts  or  for 
tubal  dropsies.  Nevertheless  evacuation  by  the  vagina  may  be  tried 
if  symptoms  occur  which  seem  to  indicate  it,  and  in  the  absence  of  any 
centra-indication. 

IV.  Tumours  of  the  broad  ligaments. — These  are  fibrous  tumours, 
myomata,  cysts  of  Eosenmiiller's  organ,  hydatid  cysts,  &c.,  without 
counting  the  abscesses  described  when  treating  of  perimetritis  and 
tumours  of  the  tubes,  ovaries,  or  uterus  insinuated  by  their  progressive 
development  between  the  folds  of  these  ligaments. 

1»  Fibrous  tumours  and  myoynata  of  the  broad  ligaments. — These 
must  not  be  confounded  with  sub-serous  or  intra-parietal  myomata  of 
the  displaced  uterus  which  have  been  expelled  as  an  effect  of  their 
development  and  have  become  intra-ligamental.  They  may  also  be 
developed  in  the  round  ligament,  as  in  the  case  of  stone  in  the  round 
ligament  mentioned  by  Walter.  Diagnosis  is  uncertain,  treatment  is 
the  same  as  that  for  ovarian  and  peri-uterine  fibroma. 

>  Puistienne,  op.  cit.,  p.  47. 

"  Memoires  de  la  Societe  de  chirurgie,  t.  iii,  p.  121.  Paris,  1856. 


PELVIC    TUMOURS  781 

2.  Cj/sts  of  the  broad  ligaments  occur  more  frequently  in  children 
than  in  adult  women,  in  the  folds  of  the  broad  ligament,  between  the 
l^allopian  tube  and  ovary,  and  especially  in  the  lower  portion  of  the 
tube  near  the  fimbriated  extremity;  they  are  small  cysts  varying  in 
size  from  that  of  a  millet  seed  to  a  small  nut,  sometimes  sessile,  more 
frequently  attached  by  a  pedicle  of  from  one  quarter  to  two  inches 
long ;  the  envelope  and  contents  are  transparent  and  are  usually 
regarded  as  the  remains  of  one  or  more  blind  tubes  of  Eosenmiiller^s 
organ  (fragments  of  the  Wolffian  body).i  Whether  they  are  produced 
by  an  abnormal  dilatation  of  one  of  the  elements  of  the  Wolffian  body, 
or  whether  they  result  from  a  new  formation,  as  Yirchow-  supposes, 
pediculated  cysts  are  chiefly  met  with  in  children  and  cannot  be  diag- 
nosed during  life ;  interstitial  cysts  (between  the  folds  of  the  broad 
ligament)  may  attain  the  size  of  an  egg,  an  apple,  or  even  of  a  foetal 
head.  They  have  a  tendency  to  remain  stationary,  and  may  disappear 
suddenly  by  rupture.^  Diagnosis  is  uncertain.  If  they  do  not  dis- 
appear by  resolution,  and  if  they  become  large,  they  may  be  removed 
by  operation  similar  to  that  for  ovarian  cysts.  It  is  for  these  cysts  that 
enucleation  without  either  section  or  ligature  of  the  pedicle  may  be  tried. 
As  for  hydatid  cysts  of  the  ovaries  and  broad  ligaments,  the  same  re- 
marks apply  to  them  as  to  the  same  tumours  in  any  other  part  of  the 
abdominal  or  pelvic  cavities. 

V.  Abdominal  and  pelvic  tumoitrs  common  to  both  sexes,  but  giving 
rise  in  the  woman  to  errors  of  diagnosis, — Those  which  seem  to  me  to 
have  a  special  claim  to  mention  are :  the  so-called  encysted  dropsy  of 
the  peritoneum,  hydatid  cysts,  and  floating  tumours  of  the  abdomen. 

1.  Sero-purulent  cysts  of  the  peritoneum. — These  are  serous  and 
sometimes  purulent  collections  between  the  peritoneum  and  the  abdo- 
minal muscles,  or  rather  abdominal  walls,  in  the  sub-peritoneal 
cellular  tissue,  sometimes  between  the  parietal  or  visceral  peritoneum 
and  a  broad  false  membrane  limiting  an  enclosed  space  in  some  region 
of  the  serous  membrane,  especially  in  the  pelvic  cavity.  Therefore  we 
may  distinguish  :  parietal  cysts  and  intra-abdominal  cysts.  The  former 
are  usually  situated  in  front,  but  are  occasionally  found  behind.^  The 
latter  are  formed  either  in  the  epiploon  or  by  adhesion  and  the  encyst- 
ing of  a  fluid  in  an  accidental  intra-peritoneal  cavity.  Sometimes  even 
a  hydatid  cyst  may  exist  simultaneously  in  the  abdominal  wall.^  These 
collections,  described  as  early  as  the  16th  century,  were  attributed  by 
Nuck^  to  an  effusion  in  the  space  between  the  peritoneal  fold  which  was 
supposed  to  be  double  ;  but  they  could  not  have  such  an  origin.  Not 
only  do  they  seem  to  be  exclusively  situated  either  in  the  sub-peritoneal 

'  Verneuil,  Recherches  sur  les  kystes  de  I'organe  de  Wolff  {Memoires  de  la 
Sac.  de  chir.,  t.  iv,  p.  58.  Paris,  1854). — Kceberle,  art.  Ovaike  in  Diet.,  &c. 

■'  Op.  cit.,  t.  i,  p.  260. 

^  West,  op.  cit.,  p.  521. 

■*  Boinet,  Bulletin  de  la  Sac.  Anal.,  t.  xix,  p.  285 ;  t.  xxvii,  p,  20. — Puis- 
tienne,  Tumeurs  enhystees  pelviennes  et  abdominales,  p.  75.  Paris,  1866. 

*  Degner,  Act.  nov.  curios,  naturae,  t.  v,  Obs.  2. 

fi  Observations  rares  de  medecine,  t.  ii,  p.  176.  Paris,  1758. 


782  UTERINE    DISEASES   IN    DETAIL 

cellular  tissue  or  in  an  adventitious^  intra-peritoneal  cavity,  but  they 
are  apparently  almost  always  the  consequence  of  peritonitis.  The 
researches  of  Bernutz^  tend  to  include  the  so-called  encysted  dropsy  of 
the  peritoneum  among  cases  of  peritonitis  encysted  by  adhesions,  as 
they  have  also  included  the  majority  of  peri-uterine  phlegmons 
among  cases  of  adhesive  suppurative  and  encysted  peritonitis.  Bernutz 
has  compared  all  the  cases  of  encysted  dropsy  of  the  peritoneum 
analysed  by  Morgagni,  as  well  as  ail  those  indicated  more  recently, 
as  examples  of  this  so-called  encysted  dropsy ;  he  has  collected  in  all 
36  cases^  and  has  not  found  in  one  any  proof  of  the  reality  of  this 
malady.  The  diagnosis  is  sometimes  so  difficult  that  they  have  been 
taken  for  ovarian  cysts.  The  treatment,  more  difficult  still,  does  not 
differ  from  that  of  pelvic  peritonitis  or  of  other  sero-purulent  intra- 
peritoneal collections. 

2.  Hydatid  cysts. — Charcot^  has  collected  12  cases  of  hydatids  of 
the  pelvis,  6  in  women,  2  in  which  the  hydatids  were  originally  de- 
veloped in  the  ovary.  Several  coincided  with  the  development  of 
hydatids  in  other  parts  of  the  body.  Their  usual  starting-point  is  the 
sub-peritoneal  cellular  tissue,  either  between  the  rectum,  vagina  and 
uterus^  under  the  peritoneum  -which  forms  the  recto-vaginal  cul-de- 
sac,  or  between  the  uterus  and  bladder,  or  in  the  broad  ligaments, 
forming  a  tumour  to  the  right  and  left  in  the  vagina  (Eoux).  In 
cases  in  which  the  ovary  appeared  to  be  transformed  into  a  hydatid 
cyst  it  had  fallen  into  the  vagino-rectal  cul-de-sac  and  had  contracted 
adhesions  with  the  neighbouring  parts.  Hydatids  of  the  pelvis  form, 
in  woman,  a  smooth,  rounded,  fluctuating,  indolent  tumour,  project- 
ing towards  the  rectum  and  vagina,  or  even  above  the  pubis,  when  it 
is  developed  in  front  of  the  uterus.  The  symptoms  are  those  of  com- 
pression and  sometimes  of  inHammation.  The  presence  of  hydatid 
tumours  in  other  parts  of  the  body  is  a  valuable  element  of  diagnosis. 
The  hydatid  thrill  is  seldom  perceived.  The  escape  of  the  hydatids  is 
the  only  certain  sign.  These  tumours  are  often  confounded  with 
commencing  or  even  with  large  cysts  of  the  ovary,  especially  when 
they  are  developed  in  front  of  the  uterus,  or  in  the  epiploon,  in  the 
left  hypochondriac  region,  in  the  liver,  and  even  in  the  kidney.  The 
treatment  is  the  same  as  for  hydatid  cysts  of  the  abdomen  in  man  : 
the  potential  cautery,  opening  of  the  sac,  destruction  and  expulsion 
of  the  hydatids,  injection  and  compression  of  the  cyst. 

3.  Floating  tumours  of  the  abdomen  are  ovoid,  of  the  size  of  a 
turkey's  egg,  solid  in  consistency,  usually  situated  in  the  right  hypo- 
chondriac region  or  in  the  loins,  rarely  on  the  left,  sometimes  on  both 
sides  symmetrically,  descending  even  to  the  iliac  region ;  they  are 
seldom  seen  in  man  but  frequently  in  women.  According  to  Cru- 
veilhier,^  Pritz,^  West,*^   and  other   observers  they  are  only  floating 

^  Guyon,  Diet,  encyclopedique  des  sc.  medic,  art.  Abdomek,  i,  183. 
^  Unpublished  paper,  quoted  by  Puistienne,  op.  cit.,  p.  76. 
^  Mem.  sur  les  tumeurs  hydatiques  du  petit  hassin  {Gazette  medicale  de 
Paris,  1852). 

■•  Anatom.  patholog.  generale,  t.  ii,  p.  72.3. 

^  Archiv.  gen.  de  med.,  1859,  t.  ii.  pp.  158,  301. 

«  Op.  cit.,  p.  559. 


PELVIC    TUMOURS  783 

hiclneys,  expelled  from  their  natural  position  by  a  sudden  shock  or  by 
the  exaggerated  and  continuous  compression  of  corsets  (Cruveilhier). 
They  are  more  easily  distinguished  from  tumours  of  the  ovaries,  broad 
ligaments  and  tubes  than  the  majority  of  the  other  abdominal  or  pelvic 
tumours  which  I  have  just  described. 

VI.  Extra-uterine  pregnancy. — Wherever  the  seat  of  the  extra- 
uterine pregnancy  may  be,  whether  it  is  ovarian,  tubal,  tubo-inter- 
stitial  or  abdominal,  it  has  among  other  consequences  that  of  pro- 
ducing a  tumour  which  owing  to  its  position  and  the  variable  sym- 
ptoms by  which  it  is  accompanied,  often  passes  either  for  a  malady  of 
the  uterus  or  of  the  annexes.  I  shall  only  consider  it  from  this 
point  of  view ;  for  its  complete  history  special  works  should  be  cou- 
sulted.i 

Biagnosis. — Three  periods  should  be  distinguished  :  1,  that  which 
corresponds  with  the  beginning  of  pregnancy  and  extends  to  the  fourth 
or  fifth  month,  till  the  foetal  movements  are  perceptible  ;  2,  that  which 
extends  from  this  time  to  the  natural  term  of  gestation  ;  3,  that  which 
follows  the  normal  period  when  delivery  should  take  place,  and 
which  is  characterised  by  the  death  of  the  foetus,  its  mummification, 
its  various  alterations,  the  suppuration  of  the  sac,  &c. 

1.  Interrupted  menstruation,  which  is  so  important  in  the  diagnosis 
of  simple  pregnancy,  is  much  less  so  here  :  whilst  there  are  cases  in 
which  the  menses  continue  abundantly  and  normally  during  the  first 
period,  there  are  others  in  which  they  cease  to  flow  from  the  first  appear- 
ance of  pregnancy,  only  reappearing  after  the  death  of  the  child.  In 
the  majority  of  cases  vomiting  occurs  ;  it  appears  even  more  obstinate 
and  violent  than  in  normal  pregnancy.  The  mammary  glands  are  also 
usually  enlarged,  the  areola  becomes  brown,  the  tubercles  described  by 
Montgomery  are  developed,  but  it  may  be  that  this  change  of  size  is  not 
very  marked,  and  that  the  colour  of  the  areola  loses  its  importance 
from  the  fact  of  a  previous  pregnancy.  A  more  marked  phenomenon, 
described  in  all  cases  that  have  been  carefully  observed,  is  a  more  or 
less  acute  abdominal  pain  analogous  to  that  which  is  designated  under 
the  name  of  uterine  colic.  Commencing  in  most  cases  shortly  after 
conception  it  lasts  to  the  end  of  pregnancy,  with  alternations  of  in- 
crease and  diminution  \  the  seat  of  this  pain  is  in  the  hypogastrium 
and  the  flanks.  To  give  an  idea  of  the  difficulties  of  such  a  diagnosis 
I  reproduce  the  accompanying  figure  which  shows  the  general  appear- 
ance of  a  tubal  pregnancy  and  the  interesting  peculiarities  which 
characterised  this  ad-uterine  pregnancy  (i.  e.  in  one  cornu  of  the 
uterus),  which  in  this  exceptional  case  was  taken  for  a  tubal  preg- 
nancy. 

2.  Towards  the  fourth  month,  and  especially  in  the  beginning  of 
the  fifth,  we  are  authorised  to  be  more  explicit,  without,  however, 
being  secure  from  all  error.  There  was  a  well-known  case  not  long- 
ago  of  a  woman  who   was   examined  by  most  of  the  physicians  and 

'  Velpeau,  Did.  de  vied,  en  30  vol.,  t.  xi^. — Dezeimeris,  Journ.  des  connais- 
sances  medico-chirurgicales,  1836. — Triadou,  Des  grossesses  extra-uterines. 
These  d'agregation.  Montpellier,  1866. 


784 


UTERINE    DISEASES  IN   DETAIL 


^^/^ 

Fig.  427. — Pregnancy  in  a  closed  cornu  of  a  uterus  bicornis,  taken  for  a  tubal 
pregnancy  (Kussmaul,  op.  cit.,  p.  155,  fig.  45  ;  from  a  preparation  by 
Heyfelder) :  a,  body  of  the  right  unicorn  uterus,  the  cavity  of  which  was 
lined  with  a  decidua  ;  6,  its  cervix  ;  c,  vagina ;  d,  top  of  the  right  cornu  ;/, 
right  ovary  ;  e,  right  oviduct ;  g,  right  round  ligament ;  7i,  left  rudimentary 
cornu  in  gestation ;  i,  tissue  uniting  the  left  to  the  right  cornu,  in  the 
midst  of  which  were  found  the  remains  of  a  canal  destined  probably  for 
a  means  of  communication  between  the  cavities  of  the  two  horns  ;  Tt,  left 
round  ligament ;  I,  muscular  fibres  proceeding  from  it  to  be  inserted  into 
the  body  of  the  right  horn  ;  m,  peritoneum  ;  n,  left  oviduct ;  o,  left  ovary, 
with  a  very  large  corpus  luteum  ;  p,  laceration  of  the  gestatory  portion  ; 
q,  placenta ;  r,  membranes  of  the  ovum  ;  s,  umbilical  cord  ;  t,  embryo. 


PELVIC    TUMOURS  785 

surgeons  of  the  Paris  hospitals^  and  considered  as  having  an  extra- 
uterine pregnancy,  and  who  was  delivered  naturally  at  the  end  of  the 
ninth  month  to  the  great  astonishment  of  Huguier,  who  pubhshedthe 
instructive  case  :  it  is  right  to  mention  that  Dubois  was  not  mistaken 
in  it.  In  an  analogous  circumstance  Pajot  diagnosed  a  normal 
pregnancy  in  an  exceptionally  attenuated  uterus,  a  diagnosis  which 
proved  to  be  correct.  I  have  seen  a  similar  case  taken  for  extra- 
uterine pregnancy  by  a  justly  esteemed  practitioner  ;  I  not  only  cor- 
rected the  diagnosis  but  prognosed  premature  delivery,  which  soon 
occurred.  In  another  case  Schlesinger^  diagnosed  an  ovarian  preg- 
nancy in  a  woman  who  was  delivered  normally  at  term  :  the  cause  of 
this  error  was  a  tumour  in  the  right  inguinal  region. 

Though  in  such  cases  it  is  easy  to  make  a  mistake,  there  are  nume- 
rous indications  authorising  the  physician  to  pronounce  a  decided 
opinion.  We  observe  on  the  one  hand  that  there  is  pregnancy,  from 
the  foetal  movements  and  from  the  information  furnished  by  ausculta- 
tion ;  on  the  other  hand,  that  it  has  an  unusual  position,  as  examina- 
tion by  the  vagina  and  abdomen  discovers  a  tumour  situated  on  one 
side,  painful  on  pressure  and  distinct  from  the  uterus,  the  upper  limits 
of  which  can  often  be  felt. 

The  difficulty  of  effecting  iutra-uterine  hallottement,  the  small  size 
of  the  womb,  the  displacements  of  this  organ  above,  below,  or  to  one 
side,  according  to  the  position  of  the  extra-uterine  cyst,  are  all  indi- 
cations of  extra-uterine  pregnancy.  Lastly,  when  the  natural  term 
of  pregnancy  arrives,  the  patient  is  attacked  by  labour  pains ;  these 
pains  are  prolonged  for  three  or  four  days,  cease  and  return  at 
intervals  without  ejffecting  anything.  This  symptom  alone  would 
serve  as  a  certain  basis  for  diagnosis  if  any  was  required  at  this 
period. 

3.  When  the  foetus  is  dead,  we  must  judge  from  the  history  of  the 
case,  i.e.  from  the  previous  symptoms  which  may  pass  as  signs  of  ges- 
tation and  of  extra-uterine  pregnancy.  Besides  these,  direct  examina- 
tion, palpation,  touch,  the  perception  of  irregularities  characteristic  of 
the  various  segments  of  the  foetus  through  the  sac  which  encloses 
them,  &c.,  will  help  in  distinguishing  the  foetal  cyst  from  ovarian, 
tubal  or  abdominal  tumours,  whether  solid  or  fluid,  serous  or  puru- 
lent, traumatic,  inflammatory,  or  diathetic,  with  which  they  might  be 
confounded. 

Treatment. — It  is  rare  for  extra- uterine  pregnancy  to  reach  its 
natural  term  :  the  statistics  of  Campbell,  Hecker  and  Mattei,  as  well  as 
those  which  Puech  has  communicated  to  me,  prove  that  it  is  quite  an 
exceptional  circumstance.  In  three  quarters  of  the  cases  the  cyst  is 
ruptured  before  this  period.  This  termination,  which  is  rather  less 
frequent  in  abdominal  pregnancy,  may  be  said  to  be  the  rule  in  inter- 
stitial, tubal  and  ovarian  pregnancies. 

Extra-uterine  pregnancies  are  susceptible  of  different  terminations. 
Sometimes  the  cyst  is  ruptured,  and  then  this  rupture  either  produces 
a  hsemorrhage  which  is  fatal  in  a  few  hours,  or  acute  peritonitis  fatal 
1   Casper's  Wochenschrift,  1845,  No.  31. 

50 


786  UTEEINE   DISEASES    IN    DETAIL 

in  from  two  to  ten  days^  or  circumscribed  peritonitis  which  may  be 
successfully  treated.  In  the  latter  case,  matters  may  go  on  just  as 
when  the  cyst  does  not  rupture.  Sometimes  the  cyst  does  not  rupture 
and  resists  the  pressure  exercised  on  it  from  within  by  its  contents. 
The  embryo  then  dies  prematurely,  or  it  reaches  the  ultimate  limits  of 
its  development  and  dies  from  insufficient  nutrition.  In  both  cases  it 
may  happen  that  the  cyst  is  tolerated,  or  that  nature  makes  efforts  to 
expel  it.  When  tolerance  is  established  the  cystic  walls  are  modified, 
vascularisation  diminishes  and  the  amniotic  fluid  is  absorbed;  the 
product  of  conception  shrinks  and  shrivels  up,  and  undergoes  the 
waxy  transformation  of  which  there  are  numerous  examples,  Puech 
having  collected  35  cases.  When  tolerance  cannot  be  established, 
which  is  especially  observed  when  the  foetus  is  large,  the  latter  irri- 
tates the  neighbouring  parts  by  its  presence,  provoking  expulsive 
efforts.  The  cystic  walls  become  inflamed,  contract  adhesions  with 
the  neighbouring  parts  and  cause  death  more  or  less  rapidly,  accord- 
ing to  the  degree  of  inflammation,  and  also  according  to  the  strength 
of  the  patient.  Peritonitis  is  therefore  the  most  frequent  cause  of 
death ;  next  to  it  come  exhaustion,  hectic  fever  and  purulent  infec- 
tion. More  frequently  nature  creates  an  exit  for  the  contents  of  the 
cyst,  either  externally  or  into  a  cavity.  After  more  or  less  serious 
symptoms  have  lasted  for  some  time,  an  abscess  is  formed  and  opens 
at  some  part  of  the  abdominal  walls,  into  the  interior  of  the  rectum, 
or  more  rarely  into  some  other  point  of  the  intestinal  tube,  into  the 
vagina,  into  the  bladder,  or  it  may  be  that  it  escapes  by  several  of 
these  channels  simultaneously :  vagina  and  umbilicus,  rectum  and 
bladder,  rectum  and  vagina.  Nothing  is  more  variable  than  the 
period  when  this  work  of  elimination  commences ;  it  has  occurred 
immediately  after  the  death  of  the  foetus,  and  at  other  times  ten  or 
twenty-five  years  later.  Of  all  points  of  exit  the  rectum  is  undoubt- 
edly the  most  dangerous,  but  it  is  not  so  serious  as  has  been  said,  for 
out  of  69  cases  there  were  45  cures.  It  is,  however,  serious  enough, 
causing  as  many  deaths  as  all  the  others  put  together. 

Extra-uterine  pregnancy  is  one  of  the  most  dangerous  conditions 
that  can  be  met  with ;  although  the  maximum  of  danger  is  at  the 
beginning,  since  a  woman  in  apparent  heaUh  may  succumb  in  a  few 
hours,  it  must  not  be  forgotten  that  danger  continues  to  the  end ; 
hence  the  necessity  of  medical  intervention  and  the  obligation  of  laying 
down  rules  for  the  conduct  of  such  cases.  The  indications  vary 
according  to  the  three  principal  periods  of  the  disease  already  men- 
tioned. 

1.  In  consequence  of  the  danger  which  threatens  the  mother,  and 
the  inevitable  death  of  the  child,  we  are  justified  in  considering 
whether  it  would  not  be  better  to  arrest  this  pregnancy  from  the 
beginning  by  preventing  the  development  of  the  embryo.  There  are, 
however,  serious  practical  difficulties  in  the  way  of  various  kinds, 
especially  those  relating  to  the  difficulty  of  diagnosis ;  for  it  is  really 
impossible  to  diagnose  an  extra-uterine  pregnancy  with  certainty 
before  the  second  month.     Now   statistics  prove  that  it  is  at  this 


STEEILITT  787 

period  that  the  most  serious  consequences  of  interstitial  or  tubal  preg- 
nancies might  be  most  certainly  prevented,  and  that  there  is  some 
chance  of  triumphing  over  the  dangers  inherent  to  this  state. 

However  that  may  be,  if  we  succeed  in  making  a  diagnosis  we 
should  not  hesitate  to  inject  atropine  or  morphia  into  the  tumour, 
using  a  syringe  with  a  long  cannula,  as  Friedreich  ^  did,  to  arrest  the 
development  of  the  embryo  and  the  increase  of  the  tumour  simultane- 
ously. We  could  also  arrive  at  the  same  result  by  electro-acupunc- 
ture as  employed  by  Burci  and  Bartoloni  ^  in  a  case  of  tubal  pregnancy 
at  the  third  month  ;  I  should  however  prefer  the  former  method. 

2.  The  difficulties  of  diagnosis  diminish  in  the  fourth  and  fifth 
month ;  therefore  I  hesitate  less  to  recommend  injections  being  made 
into  the  cyst  at  that  time,  being  convinced  that  they  would  be  useful 
and  that  we  could  act  with  more  chance  of  certainty. 

It  is  true  that  at  that  time  the  foetus  would  only  be  sacrificed  at  an 
advanced  stage  of  gestation,  and  that  the  ulterior  accidents  of  elimina- 
tion would  not  be  so  surely  prevented.  This  serious  decision  however 
should  never  be  made  without  a  consultation ;  even  at  this  period  it 
is  not  always  easy  to  diagnose  extra-uterine  pregnancy.  If  the  child 
has  reached  the  ninth  month  and  is  still  living  and  if  the  mother 
desires  an  operation,  gastrotomy  might  be  attempted,  although  there 
is  little  hope  of  success.  In  this  case  as  in  those  in  which  the  child 
is  dead,  an  incision  should  be  made  as  nearly  as  possible  at  the  point 
where  the  foetal  head  is  supposed  to  be,  the  only  reason  for  another 
point  being  chosen  would  be  the  fact  of  its  being  lower  down  and  of 
the  skin  being  thinner. 

3.  When  pregnancy  is  more  advanced,  when  the  child  is  dead  and 
the  mother  suffers  only  moderately,  we  may  wait,  but  if  a  process  of 
elimination  is  developed,  intervention  is  indicated,  either  by  opening 
the  tumour  with  Yienna  paste,  or,  if  it  is  already  opened,  by  enlarging 
the  orifice  with  the  bistoury,  so  as  to  be  able  to  extract  the  bones  and 
foetal  fragments  more  rapidly. 

As  for  the  point  of  incision  in  such  cases  it  ought  to  be  where  this 
work  of  elimination  is  being  carried  on ;  if  this  points  in  several 
directions,  the  abdominal  wall  should  be  preferred. 

Sterility 

Sienl'ity^  may  be  the  result  of  three  distinct  conditions,  the  cause 
of  which  is  more  especially  dependent  on  the  woman,  the  seat  of 
which  is  deeper,  and  the  cure  more  difficult  in  proportion  as  we  pass 
from  the  first  to  the  second  and  from  the  second  to  the  third. 

1  Gaz.  hehdom.,  1864,  p.  716 

^  Union  medicale,  4  April,  1857. 

'  As  for  the  importance  of  sterility  in  gjnsscologj,  it  is  sufficient  to  mention 
that  Simpson,  making  investigations  as  to  the  frequency  of  sterility,  found 
that  out  of  1252  marriages,  146,  that  is,  aboTit  1  in  S"5,  were  sterile.  Spencer 
Wells  found  also  that  1  out  of  every  8  married  women  is  sterile.  Sims 
arrived  at  the  same  result,  and  I  am  surprised  at  the  increasing  number  of 
women  who  consult  me  on  this  matter. 


788  UTEEINE    DISEASES    IN    DETAIL 

These  three  conditions  are : 

1.  Inaptitude  for  coitus  or  impotence. 

2.  Inaptitude  for  conception  or  infertility. 

3.  Inaptitude  for  germination  or  sterility  strictly  speaking. 
These  various  inaptitudes  may  be  temporary  or  permanent,  relative 

or  absolute,  curable  or  incurable.  They  are  so  in  different  degrees : 
inaptitude  for  germination,  for  example,  is  the  one  which  is  most 
frequently  incurable  and  the  most  complete. 

I.  Inajptitude  for  coitus  or  impotence. — It  is  more  limited  in  the 
woman  than  in  the  man.  The  woman  in  a  manner  playing  a  passive 
part  in  coitus  it  sufiices  for  the  vulva  and  vagina  to  be  sufficiently 
open  to  receive  the  penis  and  permit  of  copulation.  There  are, 
however,  malformations  of  the  external  genital  organs,  congenital  or 
accidental,  teratological  or  pathological,  which  may  render  a  woman 
temporarily  or  permanently  impotent. 

Vulva. — Apart  from  adhesions  of  the  labia,  which  are  always  of 
accidental  origin  and  which  hinder  intercourse,  I  do  not  know  of  any 
vulval  lesions,  strictly  speaking,  capable  of  causing  sterility  except 
the  conformation  designated  by  the  name  of  transverse  female  herma- 
phrocUsm,  for  in  such  cases,  although  menstruation  is  regular  preg- 
nancy is  exceptional. 

If  consulted  for  a  case  of  this  kind,  we  should  imitate  Coste"^  in 
making  a  vagina  and  amputating  the  clitoris  :  and  perhaps  the  desired 
result  would  be  obtained.  It  is  needless  to  say  that  this  attempt 
should  not  be  made  unless  one  is  assured  of  the  existence  of  menstrua- 
tion and  of  the  development  of  the  uterus.  The  same  precautions 
should  be  taken  in  a  case  of  absence  of  the  vulva ;  for,  with  the 
exception  of  Magee's^  and  Rossi's^  cases,  this  is  usually  accompanied 
by  the  absence  or  atrophy  of  the  uterus.  I  have  seen  women  in 
whom  excessive  length  of  the  nymphse,  inclining  towards  the  vagina 
at  the  moment  of  intromission,  constituted,  if  not  an  insurmountable 
obstacle,  at  least  a  serious  difficulty  in  the  way  of  coitus  :  in  one  case 
I  removed  them,  and  attributed  to  this  circumstance  the  cessation  of 
absolute  sterility  which  had  lasted  for  five  years ;  in  another  case,  this 
excessive  length  coincided  with  a  congenitally  narrow  os.  The 
influence  of  the  nymphse  on  sterility  ought  to  be  much  more  marked 
when  they  are  affected  with  elephantiasis  or  even  with  simple  hyper- 
trophy, the  consequence  of  syphilis  for  example. 

Vagina. — The  anomalies  of  deficiency,  bifidity,  and  the  abnormal 
opening  of  this  canal  may  be  causes  of  impotence.  Anomalies  of 
deficiency  may  be  either  congenital  or  accidental,  partial  or  total. 
The  total  or  partial  absence  of  the  vagina  from  defective  formation  or 
arrest  of  development,  imperforate  hymen,  membranous  occlusion  of 
the  lower  part  of  the  vagina,  and  extreme  narrowness  of  this  canaP 

''  Journ.  des  connaissances  med.-cMr.,  t.  iii,  p,  276,  1835. 
"  The  Lancet,  23  July,  1842,  p.  575. 
3  Annales  de  Montpellier,  t.  xiii,  p.  39. 

■*  Delaunay,  Etude  s^i,r  le  cloisonnement  transversal  du  vagin.  Tlieses  de 
Paris,  1877. 


STERILITY  789 

should  be  mentioned  in  the  first  rank.  I  shall  confine  myself  to  men- 
tioning that,  in  such  cases,  the  treatment  instituted  for  the  re- 
establishment  of  menstruation  is  the  appropriate  one  for  the  cure  of 
sterility.  Only  it  is  to  be  remarked  that,  when  retention  of  blood  is 
prolonged  for  several  years,  subsequent  disorders  of  the  uterus, 
ovaries  and  tubes  may  result,  rendering  conception  impossible.  The 
sterility  observed  by  Becasseau,  Kluyskens,  Chevalier  and  Patry^  in 
the  patients  on  whom  they  operated  may  be  explained  in  this  way. 

Congenital  narroivness  of  the  vagina  throughout  its  whole  extent  is 
rare.  Nevertheless,  Antoine,^  de  la  Toison,^  Plenck,*  Benevoh,^ 
Denman^  and  Scanzoni'^  have  given  very  curious  examples  of  it.  In 
these  cases  it  was  not  so  much  menstrual  disorders  as  difficulties  in  the 
way  of  coitus  that  attracted  the  attention  of  these  physicians.  The 
remedy  for  this  condition  is  dilatation.  When  occlusion  of  the  vagina 
is  not  complete  conception  may  occur  exceptionally,  even  when  intro- 
mission is  impossible.  I  knew  a  woman  in  whom  the  vesico- vaginal 
septum  was  destroyed  and  the  vagina  obliterated  at  the  vulva,  except 
at  one  point,  where  there  was  an  opening  large  enough  to  admit  a 
female  catheter,  by  which  the  urine  escaped ;  since  her  confinement, 
the  cause  of  this  lesion,  more  than  a  year  before,  menstruation  had 
not  occurred;  in  spite,  however,  of  these  unfavorable  conditions, 
conception  took  place,  pregnancy  arrived  at  term,  and  the  patient  died 
from  the  consequences  of  labour. 

Bifidity  of  the  vagina,  i.  e.  its  longitudinal  division,  is  only  a  cause 
of  sterility  when  the  calibre  of  the  two  vaginal  canals  is  so  contracted 
as  only  to  allow  of  imperfect  intromission,  or  when  the  half  of  the 
organ  in  which  coitus  is  practicable  ends  in  an  atrophied  half  of  a 
uterus.  Laaser^s^  case  may  be  mentioned  as  an  example  of  the  latter 
category.  In  such  circumstances  the  physician  may  dilate  one  of  the 
two  vaginte  artificially,  or,  if  dilatation  be  insufficient,  the  division 
may  be  removed  as  was  done  by  Laaser.  In  a  case  of  the  same  kind 
(double  uterus,  double  vagina  and  congenital  vagino-rectal  fistula)  I 
succeeded  in  destroying  the  longitudinal  division  of  the  two  vaginae 
by  the  application  of  a  long  enterotome  and  the  obliteration  of  the 
fistula  by  suture. 

There  may  be  abnormal  orifices  from  the  vagina  into  the  bladder, 
urethra  or  rectum.  The  first  anomaly,  which  is  the  rarest,  has  only 
been  observed  four  times.^  It  is  only  curable  by  surgical  interven- 
tion, i.  e.  by  the  formation  of  a  vagina,  and  the  obliteration  of  the 

^  Puech,  Des  atresies  des  voies  genitales  de  lafemme,  p.  131.  Paris,  1861. 

^  Histoire  de  I'Academie  des  sciences,  1712,  p.  36. 

3  Ibid.,  1738,  p.  58. 

^  L'art  d'accoucher,  translated  by  Pitt,  p.  lit), 

°  Delle  hernie  intest.  Florence,  1747. 

^  Diet,  en  60  volumes,  art.  Vagin. 

'  Op.  cit.,  p.  480. 

^  Monatschrift  fiir  Geburtshunde,  1864,  Bd.  x\iv,  S.  441. 

'  Chevreuil,  Journ.  de  med.  et  de  cldr.,  1772,  t.  xli,  p.  447. — Kingdon,  Gaz. 
m(''d.  de  Paris,  1838,  p.  283. — Coste,  Journ.  des  conn,  med.-chir.,  1835,  t.  iii, 
p.  276. — Huguier,  in  Lefort,  op.  cit.,  p.  203. — Puech,  Mt^m.  sur  le  cloaque  uro- 
genital (Montpellier  medical,  1868). 


790  UTERINE    DISEASES    IN  DETAIL 

abnormal  opening :  by  enabling  the  menstrual  blood  to  escape  by  the 
normal  channel  we  may  at  the  same  time  restore  the  power  of  concep- 
tion to  the  woman.  The  opening  of  the  vagina  into  the  rectum  ^  is 
observed,  on  the  contrary,  much  more  frequently  :  it  would  take  too 
long  to  mention  all  the  cases  that  I  have  collected,  nor  is  this  the 
place  to  establish  between  them  distinctions  and  divisions  interesting 
from  other  points  of  view;  it  is  enough  to  add  that  the  artificial 
/ormation  of  that  portion  of  the  vulvo -uterine  canal  which  is  wanting 
and  obliteration  of  the  abnormal  opening  are  indicated.  There  are 
cases  in  which  the  vagina,  though  apparently  normal,  is  nevertheless 
affected  with  some  imperfection  the  influence  of  which  on  sterility  is 
more  real  than  would  be  supposed.  Such  are  extreme  shortness  of  the 
vagina^  which  favours  the  formation  of  a  copulative  sac  and  projec- 
tion of  the  semen  outside  the  axis  of  the  uterine  canal;  excessive 
length  and  breadth  of  this  organ,  which  greatly  increases  the  chances 
of  the  fertilising  fluid  being  lost  in  the  anfractuosities  of  this  mem- 
branous canal  without  penetrating  the  uterus ;  lastly,  inequality  of  the 
two  vaginal  walls,  the  posterior  one  which  is  usually  the  longer  form- 
ing a  cul-de-sac  behind  the  cervix,  in  which  the  sperm  is  accumulated. 
When  a  congenital  or  acquired  narrowness  is  added  to  extreme  short- 
ness of  the  vagina  it  may  lead  to  most  troublesome  consequences. 
Barnes  says  (op.  cit.,  p.  113)  that  after  the  menopause,  especially  in 
women  who  have  not  had  uninterrupted  conjugal  relations,  the  uterus, 
vagina  and  vulva  undergo  a  kind  of  atrophic  involution,  by  which 
they  lose  their  dilatability,  and  which  may  render  coitus  not  only  pain- 
ful but  dangerous.  In  the  museum  of  St.  George's  Hospital  (series 
xiv,  108)  is  to  be  seen  a  vagina  the  fundus  of  which  was  lacerated 
in  coitus. 

Vicious  insertions  of  the  vagina  into  the  uterus  are  also  causfs  of 
inaptitude  for  fecundation.  An  anterior  or  lateral  copulative  sac  is 
formed,  or  ofteuer  still  a  posterior  one  (the  uterus  apparently  being 
inserted  in  the  anterior  wall  of  the  vagina,  sometimes  very  near  the 
vulva).  This  sac,  most  frequently  congenital,  sometimes  acquired, 
forms  a  receptacle  for  the  sperm,  which  is  always  unfavorable  to 
fecundation. 

In  place  of  being  originally  narrow,  or  subsequently  contracted, 
the  vagina  and  vulva  may  be  in  a  state  of  coarctation  produced  by 
vaginismus  or  spasmodic  contraction  of  the  vagina  and  of  the  sphincter 
cunni.  The  efi'ect  of  this  nervous  malady  is,  that  the  introduction  of 
even  a  small  foreign  body  into  the  vaginal  canal  sometimes  determines 
such  acute  pain  as  to  produce  syncope,  which  makes  coitus  for  the 
time  impossible.  This  state  may  last  for  years  if  not  remedied  by 
forced  dilatation  or  other  means.  In  a  case  of  the  kind  conception 
was  effected  during  antesthetic  sleep. ^ 

1  Murat,  Diet,  en  60  vol.,  art.  Vagin. — Isid.  Geoffroy-Saint-Hilaire,  Ano- 
malies cle  V organisation,  t.  i,  p.  501. — Boiiisson,  Des  vices  cle  conformation  de 
I'anus  et  du  rectum,  p.  39.  Paris,  1851.     Eoubaud,  op.  cit.,  t.  ii. 

^  I  have  several  times  seen  the  vagina  shorter  than  usual,  as  in  Pfau's  case, 
where  after  maniage  it  was  only  1^  inch  long. 

'  Sims,  op.  cit.,  p.  343. 


STERILITY  791 

II.  Inaptitude  for  conception  or  infertility/  may  either  depend  on 
mechanical  or  physiological  causes.  The  sperm  is  hindered  from 
coming  in  contact  with  the  ovum  sometimes  by  direct  obstacles  to  the 
penetration  of  the  semen,  or  by  disease  of  the  parts  which  the  sperma- 
tozoa have  to  traverse ;  sometimes  by  a  merely  functional  impo- 
tence, a  physiological  alteration  of  the  means  of  transport  for  the 
fertilising  fluid  or  the  localisation  in  these  organs  of  a  general  morbid 
condition.  Obstacles  to  conception  are  the  most  common  causes  of 
sterility  :  some  are  incurable  ;  others_,  although  numerous  and  depen- 
dent on  various  conditions,  may  be  overcome  and  frequently  yield  to 
local  or  general  treatment  which  may  be  applied  according  to  the 
indications. 

1.  Mechanical  and  organic  obstacles  to  conception. — They  may 
exist  in  the  uterus  or  in  the  tubes,  or  may  result  from  the  presence  of 
pathological  fluids  in  these  organs,  or  of  secretions  unfavorable  to  the 
preservation  of  the  germs.  The  sterility  is  sometimes  incurable,  at 
other  times,  on  the  contrary,  it  may  be  treated  with  more  or  less 
chance  of  cure,  according  to  the  nature  and  extent  of  these  obstacles. 

Absence  of  the  uterus  and  the  embryonic  condition  of  this  organ 
cause  absolute  sterility  .^ 

The  uterus  sometimes  preserves  its  foetal  or  infantile  characteristics 
even  after  puberty;  it  may  be  either  simple,  imperforate  (Duplay),  or 
bicorn  (Wehr  of  Cassel).  This  condition  is  apparently  incurable, 
whichever  variety  occurs.  Meadows,^  in  a  case  of  this  kind,  has 
tried  galvanic  sounds  and  pessaries,  which  however  only  produced 
acute  irritation. 

Under  the  name  of  pubescent  ^  uterus  Puech  has  designated  the 
uterus  which  preserves  after  puberty  the  characteristics  peculiar  to 
this  organ  during  the  period  of  transition  between  childhood  and 
puberty.  He  has  seen  two  cases,  one  of  which  was  confirmed  by 
autopsy.  In  the  latter  case,  although  the  woman  had  been  a  prostitute 
for  twelve  years,  she  had  never  menstruated ;  in  the  other,  a  woman 
of  forty,  haemorrhage  from  the  vulva  had  only  occurred  three  times  at 
long  intervals.  The  vaginal  portion  of  the  cervix  is  small  and  conical 
or  presenting  a  warty  projection  of  the  size  of  a  pea,  the  meatus  is 
very  small.  The  incomplete  development  of  the  uterus  is  discovered 
by  vaginal  and  rectal  touch ;  by  the  latter,  the  upper  borders  of  the 
organ  are  easily  reached  or  exceeded.  A  probe  introduced  through 
the  cervix  demonstrates  with  certainty  the  defective  length.  Notwith- 
standing what  has  been  said  by  Scanzoni  as  to  the  incurability  of  this 
lesion,  it  should  be  treated  by  the  means  indicated  for  uterine  atrophy, 

'  If  absence  of  the  uterus  is  the  result  of  an  operation,  sterility  is  not 
absolute.  I  have  mentioned  the  case  of  a  lady  on  whom  Ivoiberle  had  operated 
(ablation  of  the  uterus),  but  in  wliom  he  had  unfortunately  left  the  ovaries. 
A  small  fistula  having  persisted,  which  formed  a  communication  between 
the  vagina  and  abdominal  cavity,  this  unfortunate  woman  had  an  extra- 
uterine abdominal  pregnancy,  a  most  remarkable  occurrence,  showing  the 
limited  part  which  the  uterus  plays  in  the  accomplishment  of  reproduction. 

2  Gaz.  vied.,  18(35,  p.  10. 

^  Incomplete  development  of  Kiwisch,  Rokitansky  and  Scanzoni.    See  p.  80. 


792  UTERINE   DISEASES    IN    DETAIL 

especially  by  electricity  or  by  Simpson's  galvanic  pessary,  the  intro- 
duction of  which  may  be  accompanied  when  necessary  by  dilatation. 
Iron  and  other  tonics  should  also  be  administered.  The  uterus  may 
be  to  all  appearance  normally  developed  and  yet  have  no  cavity,  either 
owing  to  arrested  development  of  Miiller's  canals  when  they  are  still 
solid,  from  the  eighth  to  the  tenth  week,  or  as  the  result  of  precocious 
adhesions  of  the  opposite  walls  of  the  mucous  membrane.  This  very 
rare  state,  of  which  Boivin  and  Duges  give  an  example,  is  like  the  pre- 
ceding compatible  with  perfect  health,  and  is  manifested  by  the 
absence  of  menstruation,  and  of  the  signs  of  menstrual  retention,  not- 
withstanding the  existence  of  symptoms  of  monthly  ovulation ;  by  the 
impossibihty  of  conception,  although  intercourse  may  be  easy ;  by  the 
imperforation  and  impenetrability  of  the  uterus  in  spite  of  the  deve- 
lopment and  external  appearance  of  this  organ  being  almost  normal. 
.  Uterine  atrophy  is  all  the  more  deserving  of  attention  because  it  may 
be  followed  by  cure,  and  consequently  by  the  cessation  of  sterility.  It  is 
caused  in  the  same  way  as  atrophy  of  the  ovaries  or  is  produced  after 
labour  from  the  excessive  retrograde  evolution  which  takes  place  in  the 
uterus  at  this  period  (p.  621).  I  have  already  spoken  of  the  cases 
mentioned  by  Simpson  in  describing  this  remarkable  malady ;  I  have 
seen  several  myself ;  Puech  has  observed  the  same  disease  in  a  woman 
after  delivery  and  eleven  months^  lactation ;  and  in  another  after 
repeated  miscarriages.  Although  there  is  little  hope  of  cure  for  this 
state  when  it  is  of  long  standing,  the  physician  should  not  remain 
inactive;  he  should  on  the  contrary  strengthen  the  constitution  by 
tonics,  hydropathy  and  sea-bathing,  and  also  apply  electricity  to  the 
uterus,  introduce  galvanic  stems,  and  so  endeavour  to  produce  new 
vitality  in  the  organ.  There  will  be  all  the  more  chance  of  success,  if 
treatment  is  instituted  soon  after  delivery.  Uterine  atrophy  may  affect 
the  whole  uterus,  or  only  one  of  its  segments.  The  same  treatment  is 
appKcable  to  either  segment,  and  to  the  whole  uterus. 

Simple  or  complicated  imj)erf oration  of  the  cervix  is  a  cause  of 
sterility  which  may  be  treated  successfully,  especially  if  it  coincides 
with  normal  conformation  -,  for  it  is  frequently  accompanied  by  an 
abnormal  position  and  form.  It  is  the  same  with  septa  situated  in  the 
vagina  more  or  less  near  the  cervix,  imperforate  or  pierced  with  a  hole, 
or  membranous  contractions  of  this  canal  which,  without  being  a 
cause  of  impotence,  yet  prevent  conception ;  it  is  the  same  with  con- 
genital narrowness  or  accidental  contractions  of  the  os,  which  is  so 
frequent  a  cause  of  mechanical  dysmenorrlicea.-^  I  have  already  spoken 
of  these  pathological  states  (p.  305) ;  and  shall  only  remark  here  that 
they  play  an  important  part  in  sterility,  and  that  as  they  are  not  always 
accompanied  by  menstrual  disorders,  it  is  easy  to  misinterpret  the  real 
cause  of  sterility  in  these  cases  if  a  direct  examination  is  not  made. 
I  have  also  described  the  treatment  which  is  suitable  for  them  during 
the  paroxysms  of  pain  attending  menstruation,  as  well  as  in  the  inter- 
calary periods,  in  palliative  as  well  as  in  radical  cure ;  and  shall  only 
further  remark,  that   radical   cure  is  only  produced  by  dilatation  or 

Oldham  was  the  first  to  use  tliis  name  {London  Med.  Gaz.,  vol.  ii,  p.  919). 


STEEILITY  793 

double  incision  of  the  cervix  (p.  313).  Local  treatment  should  always 
be  followed  by  general  tonic  treatment  and  diathetics,  according  to  the 
case,  and  by  the  use  of  ergot,  electricity,  purgatives,  &c.,  with  the 
object  of  resolving  the  congestive  condition  due  to  the  long-standing 
atresia  or  contraction. 

Congenital  or  consecutive  contractions  may  affect  the  os  internum. 
They  should  be  treated  in  the  same  way  as  those  of  the  vaginal  orifice, 
by  gradual  dilatation,  which  is  less  dangerous  and  more  lasting  in  its 
effects  than  simple  incision.  It  is  the  same  when  they  affect  the  two 
orifices  of  the  cervix  simultaneously,  and  provided  there  is  neither 
contraction  nor  atrophy  of  the  cervical  cavity,  we  may  hope  for  cure. 
Dilatation  has  the  great  advantage  of  being  resolvent  as  well  as  dilative ; 
so  that  in  some  cases  gradual  dilatation  by  sponge  tents  may  not  only 
procure  a  palliative  but  a  radical  cure  in  contractions  of  the  uterus  as 
in  contractions  of  the  urethra,  especially  if  we  associate  with  the 
mechanical  action  the  chemical  one  of  medicaments  such  as  bella- 
donna, the  red  oxide  of  mercury  and  others,  in  the  form  of  resolvent 
ointment  covering  the  tent;  it  is  also  useful  to  administer  these  drugs 
in  enemata,  and  to  pour  glycerine  on  the  cervix,  keeping  it  there  by  a 
large  plug  of  cotton  wool ;  for  it  softens  the  cervix  as  well  as  con- 
tributing to  the  cessation  of  the  contraction  or  relaxation  of  the 
orifice. 

Torsion-oi  the  body  on  the  cervix  (pp.  309,  430)  is  another  mecha- 
nical alteration  producing  effects  of  the  same  kind,  and  in  consequence 
of  which  a  deviation  occurs  which  renders  penetration  of  the  sperm 
difficult  or  impossible.  The  long  continued  use  of  laminaria  tents, 
which  act  simultaneously  by  enlarging  and  straightening  the  isthmus, 
greatly  facilitates  conception.  It  is  unnecessary  to  say,  that  the  asso- 
ciation of  general  means  with  local  applications  is  still  more  important 
here  than  in  the  preceding  cases ;  for  torsion  of  the  isthmus  is  almost 
always  dependent  on  flexion,  softening  of  the  uterine  tissue,  or  con- 
secutive chronic  congestion,  and  consequently  requires  the  use  of 
resolvents,  restoratives,  tonics,  sea-bathing  and  especially  hydro- 
pathy. 

Flexions  ^  are  causes  of  sterility  when  well  marked,  and  the  sterility 
is  incurable  when  the  flexion  is  kept  up  by  adhesions  and  cicatricial 
bands  which  make  it  impossible  to  straighten  the  uterus.  There  are 
two  causes  of  sterility  in  such  cases :  the  first  is  the  mechanical 
obstacle,  which  hinders  facility  of  communication  between  the  cervical 
and  uterine  cavities  at  the  isthmus :  the  second,  the  alteration  of 
tissue,  the  morbid  state,  the  softening  under  the  influence  of  which 
flexion  is  produced  and  maintained.  It  is  unnecessary  to  add  that 
when  adhesions  prevent  reduction  of  the  flexion,  especially  of  retro- 
flexion, these  adhesions  not  only  prevent  conception  by  hindering  the 
straightening  of  the  organ,  but  further,  are  the  indications  of  a  previous 
inflammation  of  the  uterus.  Fallopian  tubes  and  ovaries,  or  of  peri- 
uterine inflammation.     In  such  cases  there  are  almost  always  altera- 

1  Lumpe,  Considerations  sur  la  sterilite  causee  par  Vinjiexion  de  I'uterus 
{Monatschr.,  &c.,  1864,  Bd.  xxiv,  S.  69). 


794  UTERINE    DISEASES    IN    DETAIL 

tions  of  the  uterine  mucous  membrane,  obliterations  of  the  tubes, 
alteration  of  the  normal  relationship  of  the  ovary  with  the  oviduct, 
vicious  adhesions  of  the  uterus  and  annexes,  which  are  additional 
causes  of  sterility.  I  do  not  therefore  speak  of  the  means  of  treat- 
ment to  be  employed  in  such  circumstances.  In  the  case  of  simple 
flexion  we  must  endeavour,  especially  in  a  young  woman,  to  straighten 
the  organ  (p.  420).  In  cases  of  complex  flexion  we  may  be  obliged 
to  perform  partial  section  of  the  convex  lip  of  the  cervix,  in  order  to 
form  a  direct  course  for  the  semen  through  the  cervico-uterine  canal 
(see  rig.  283,  p  426). 

Sometimes  simple  version,  or  defective  relations  between  the  male 
organ  which  ejaculates  the  semen  and  the  uterine  meatus  which  ought 
to  receive  it,  is  sufficient  to  render  penetration  of  the  sperm  very 
difficult  if  not  impossible  and  to  prevent  conception.^ 

Sterility  caused  bj  retroversion  may  be  remedied  by  means  of 
Hodge^s,  Meigs's  or  Sims's  ring  pessaries,  which  take  up  very  little 
room  in  the  vagina  and  which  are  no  obstacle  to  marital  intercourse. 
Sims  2  gives  several  examples,  among  others  that  of  a  lady  who  had 
three  children,  conception  being  due  to  the  use  of  an  annular  pessary 
during  coitus ;  he  mentions  the  case  of  other  women  who  by  the  use 
of  these  pessaries  till  the  fifth  month  were  able  to  bring  their  preg- 
nancy to  the  full  term.  If  permanent  cure  cannot  be  obtained  tem- 
porary replacement  is  easily  effected  by  posture,  the  association  of 
palpation  with  digital  touch,  and  by  the  use  of  the  sound.  Provided 
this  replacement  lasts  for  some  hours,  or  can  be  effected  by  the 
husband  during  intercourse,  it  is  sufficient  to  make  conception  pos- 
sible.    I  have  seen  several  remarkable  cases  of  this  kind. 

Every  alteration  in  the  cervix  and  os  uteri  (alteration  in  size,  form 
and  structure,  ulcerations,  induration,  &c.)  becomes  a  cause  of 
sterility  from  the  difficulty  which  it  places  in  the  way  of  the  accom- 
plishment of  the  cervical  functions.  The  erection  of  the  uterus  ex- 
cited by  ovulation  and  coitus,  as  Houget's  researches  show,  plays  an 
important  part  in  conception.  The  effects  of  this  erection  on 
the  cervical  portion  cause  an  increase  in  its  size  and  induration,  suc- 
ceeded by  relaxations  and  divergence  of  the  walls,  producing  actual 
aspiration,^  as  observed  by  Beck*  on  the  cervix  of  a  multipara  affected 
with  prolapsus,  which,  when  lightly  touched,  made  five  or  six  move- 
ments of  aspiration  within  twelve  seconds,  accompanied  by  a  voluptuous 

1  According  to  Sims  (op.  cit.,  p.  237),  out  of  250  married  women,  wlio  liad 
never  had  children,  108  were  ailected  with  ante  version  and  68  with  retro- 
version ;  out  of  255  who  had  had  children,  hut  who  had  ceased  to  conceive 
before  the  menopause,  61  were  afEected  with  anteversion  and  111  with  retro- 
version ;  that  is  to  say,  out  of  505  patients  affected  with  sterility,  natural  or 
acquired,  343  pi-esented  deviations  or  flexions  of  the  womb  ;  besides,  as  about 
one  half  of  these  women  had  previously  been  pregnant,  it  is  probable  tliat 
their  acquired  sterility  depended  on  the  mechanical  lesion  of  the  organ. 

2  Op.  cit.,  p.  281. 

^  Wemich  {Beitrllge  zur  Gehurtshunde  u.  Gfyndc,  i,  296,  308). 
■*  How  do  the  spermatozoa  enter  the  uterus?  {Med.  and  Stirg.  Bepovier, 
1872). 


STERILITY  795 

sensation.  It  is  easy  to  understand  the  importance  of  any  alteration 
which  prevents  the  production  of  these  movements. 

Hypertrophy  is  the  simplest  of  all  these  alterations.  Sterility 
usually  accompanies  the  hypertrophic  elongation  of  the  supra-vaginal 
portion  which  simulates  prolapsus.  Sterility  is  never  more  certain 
than  when  there  is  a  concurrent  alteration  in  the  tubes  or  ovaries, 
often  consecutive  to  hypertrophic  elongation  and  prolapsus  of  the 
uterus.  Huguier^  says — "I  never  knew  a  woman  to  conceive  when  once 
the  elongated  uterus  had  been  so  prolapsed  as  to  have  caused  com- 
plete procidentia  and  inversion  of  the  vagina,  by  which  I  do  not  mean 
to  say  that  it  has  never  occurred ;  science  would  refute  this  assertion ; 
all  that  is  necessary  to  make  conception  possible  being  for  the  utero- 
ovarian  canal  to  be  free.^' 

Hypertrophy  of  the  vaginal  portion  is  also  a  cause  of  inaptitude  for 
conception,  whether  this  slight  hypertrophy  is  associated  with  marked 
conicity  of  the  cervix,  or  whether  it  affects  the  whole  of  the  cervix,  or 
only  attacks  one  lip.  It  was  Lisfranc^  who  first  recognised  conicity 
of  the  cervix  as  a  cause  of  sterility,  and  who  recommended  section  of 
the  cone  as  the  best  treatment.  There  is  no  doubt  that  it  is  usually 
in  cases  of  conical  cervix  that  the  penis  slips  over  the  cervix,  dis- 
charging the  sperm  in  an  accidental  copulative  sac  in  which  it  runs  a 
great  chance  of  being  lost.  It  is  certain  also  that  in  such  cases  the  os, 
whether  situated  at  the  apex  of  the  cone  or  on  one  of  its  surfaces,  is  very 
narrow  and  circular,  and  may  be  included  in  the  class  of  orifices  con- 
genitally  contracted,  for  which  I  have  advised  dilatation  and  division. 
A  considerable  sub-vaginal  hypertrophy,  whether  with  elongation  or 
with  tumefaction  of  the  lower  portion  of  the  cervix,  is  also  a  cause  of 
sterility.  This  cause  is  not  absolute,  but  it  only  yields  to  surgical 
treatment ;  if  therefore  we  can  be  sure  that  it  is  not  incurable,  we 
may  also  he  certain  that  it  cannot  be  cured  without  amputation  of  the 
hypertrophied  portion.  Dupuytren^  has  mentioned  cases  in  which 
excision  of  the  cervix  was  followed  by  conception.  I  have  seen  a 
sufficient  number  of  cases  to  convince  me  on  this  point,  and  I  can 
affirm  that  this  operation  affords  patients  a  great  chance  of  being 
cured  when  there  are  no  complications.  It  is  the  same  with  hyper- 
trophy confined  to  one  lip,  for  the  orifice  is  then  necessarily  deviated, 
or  partly  obliterated,  or  at  least  concealed  by  the  hypertrophied  lip. 
If  the  reader  wish  to  consider  the  causes  of  sterility  due  to  hyper- 
trophy of  the  cervix  from  an  exclusively  practical  point  of  view,  he 
may  refer  to  what  I  have  said  as  to  the  various  forms  which  hyper- 
trophy may  assume,  and  which  may  be  summed  up  in  the  following 
table : 

1  Op.  cit.,  p.  123. 
^  Clinique  de  la  Pitie,  ii,  139. 

3  F.  G.  Dumont,  8ur  I'agenesie,  Vvmpuissance  et  la  dysgenesie.  These  de 
Paris,  1830, 


796. 


UTEEINB    DISEASES    IN    DETAIL 


1.  Hypertrophy  of  the  whole ")   .i        ,    ■,  i-j  ... 
cei'Tix                                    \  -^^^0^^  always  morbid,  even  in  virgms. 

2.  Partial    hypertrophy    of  (  Supra-Taginal-Almost  always  morbid, 
the  cervix    \     .     ..     .Sub-vaginal     (Congenital. 

C  ^             (,  Acquired. 

f  Total  .     .     .     Very  rare  ;  it  causes  incurvation. 

3.  Hypertrophy  of  one  seg-  \  C^^  the  central  portion  or  of  the 
ment,anteriororposterio",<^  ^'^^'^^'\  t^'  '''"^^T  i  *^' 
of  the  cervix.  ^/^P^^  °^  ^^^  cervical  portion. 

Ur  the  upper  extremity  (utenne 
Partial.     .     .^      uvula). 

/'Exuberance  of 
Of   the  lower  \      one  lip. 
extremity   .  j  Dovetailing  of 
(^  V.     the  two  lips. 

Hypertrophy  of  the  whole  of  one  of  the  segments  causes  incurvation 
of  the  cervixj  the  convexity  corresponding  to  the  hypertrophied  seg- 
ment (usually  the  posterior  one),  and,  like  flexion  of  the  cervix,  some- 


FiG.  428. — Total  hypertrophy  of 
the  posterior  segment  with  in- 
curvation. 1.  section  of  the 
free  extremity  of  the  vaginal 
portion  (1st  part  of  the  opera- 
tion). 


Fig.  429. — -Total  hypertrophy  of 
the  posterior  segment.  2.  me- 
dian division  of  the  remain- 
ing vaginal  portion  (2nd  part 
of  the  operation). 


times  necessitates  amputation  of  the  lip  corresponding  to  this  segment 
(Pig.  428,  1),  followed  by  division  of  the  rest  of  the  vaginal  portion 
of  this  segment  on  the  median  line  (Pig.  429,  2),  so  as  to  make  a 
direct  course  for  the  penetration  of  the  semen  into  the  uterine  canal  ^ 
{seeY\^.  283,  p.  426). 

Partial  hypertrophy  of  one  of  the  segments  affecting  the  median 
portion  has  especially  the  effect  of  developing  the  size  of  the  central 
pilaster,  which  is  the  trace  of  the  raphe  of  the  two  primitive  uteri,  and 
of  exaggerating  the  dovetailing  of  this  central  column  of  the  arbor  vita 
with  that  of  the  opposite  segment,  or  of  one  of  the  secondary  fleshy 
columns  which  are  connected  with  it  with  the  corresponding  columns 
in  the  other  segment.  It  is  often  indeed  complicated  .with  unequal 
hypertrophies,  either  sessile  or  partly  pediculated,  which  give  to  the 
cavity  of  the  cervix  a  broken  and  mammillated  appearance.  The  best 
surgical  treatment,  in  addition  to  resolvent  medical  treatment,  consists 

^  Sims,  op.  cit.,  p.  214. 


STEEILITY 


797 


in  introducing  sponge  tents  repeatedly  and  in  performing  excision  or 
simply  abrasion  of  the  dilated  cervical  cavity,  as  well  as  in  the  local 
application  of  resolvents,  with  which  the  sponge  may  be  saturated  or 
covered,  and  finally  in  the  cauterisation  of  projecting  portions  of  the 
hypertrophied   organ  which  impede  conception.     In  order  to  make 


Fig.  430. 


Fig.  431. 


Fig.  430. — Valvular  projection  of  the  anterior  portion  of  the  isthmus. 

Fig.  431. — Sims's  curette.  I  have  had  the  concavity  sharpened,  so  as  to  use  it 
for  abrading  the  valvular  projection  of  the  isthmus,  when  caught  in  the 
terminal  fenestra  of  the  instmment.  By  suppressing  one  side  of  this 
fenestra  we  have  a  small  pruning  hook,  still  more  convenient  than  the 
curette,  and  which  I  have  frequently  had  occasion  to  use. 

this  cauterisation  easily  and  to  preserve  the  healthy  segment  from 
contact  with  or  from  the  radiation  of  the  actual  cautery,  I  take  care 
to  seize  the  cervix  with  divergent  tenaculum  hook  forceps  or  to  intro- 
duce one  of  Recamier's  large  curettes,  the  blade  of  which  serves  as  a 
conductor  for  the  very  small  cautery  employed  for  this  purpose. 

Partial  hypertrophy  affecting  one  of  the  segments  at  its  upper 
extremity  sometimes  gives  rise  to  a  kind  of  valve  or  projecting  tubercle 
(uterine  uvula),  which  must  not  be  confounded  with  a  projecting 
angle  of  flexion,  with  which  it  sometimes  coexists.     The  cervix  having 


798  UTEEINE    DISEASES   IN    DETAIL 

been  previously  dilated  by  sponge  tents,  this  little  projection  (Fig. 
430,  3)  may  be  abraded  by  means  of  a  small  hook  with  a  somewhat 
malleable  stem,  to  allow  of  variation  of  its  inclination. 

Partial  hypertrophy  of  the  lower  extremity  of  one  of  the  segments, 
i.e.  one  of  the  lips,  has  a  different  effect  according  to  whether  it  most 
affects  the  lip  on  the  side  of  the  vaginal  surface  or  on  the  side  of  the 
cervical  cavity.  If  it  affects  it  on  the  vaginal  side  it  renders  the  lip 
exuberant,  so  that  it  projects  beyond  the  orifice  which  is  above  or 
below  it ;  hence  the  acuminated  and  rostral  forms  of  the  conical 
cervix,  the  blade  and  apron-like  forms  (by  flexion)  of  the  cuneiform 
cervix,  and  the  snout-like  forms  of  the  cylindrical  cervix;  in  such  cases 
it  should  be  cauterised  or  amputated.  If  the  hypertrophy  affects  it 
on  the  side  of  the  cervical  cavity,  it  distends  the  opposite  lip,  attenuates 
it,  becomes  embedded  in  it,  giving  to  the  orifice  a  characteristic  semi- 
lunar form  (see  p.  618,  Eigs.  355,  356).  As  a  rule  I  content  myself 
with  applying  the  actual  cautery,  more  or  less  deeply,  to  the  centre  of 
the  hypertrophied  lip,  thereby  provoking  suppuration,  which  being 
followed  by  resolution  and  contraction,  raises  the  convex  border  of 
this  lip  and  rectifies  the  upper  outline  of  the  orifice  (Pig.  193,  p.  213). 
I  have  often  seen  conception  follow  this  little  operation.  In  such 
cases  the  patient  should  be  advised  to  adopt  the  prone  posture  during 
coitus. 

In  case  the  difficulty  of  rectifying  the  uterine  canal  should  suggest 
to  any  practitioner  the  idea  of  attempting  artificial  fecundation,  I  wiU 
here  describe  the  best  method  of  proceeding  so  as  to  preserve  the 
vitality  of  the  sperm  and  the  characteristic  movements  of  the  sperma- 
tozoa. The  male  organ  should  be  covered  with  a  shield,  care  being  taken 
not  to  apply  it  tightly.  Coitus  being  terminated  the  ejaculated  fluid 
will  remain  in  the  shield  which  is  then  cut  and  the  fluid  received  into 
a  small  glass  syringe  (previously  heated  by  being  placed  for  a  few 
minutes  in  water  at  a  temperature  of  40*^  C.)  furnished  with  a  metallic 
or  gutta-percha  sound,  by  means  of  which  and  by  using  great  care  it 
will  be  easy  to  make  it  penetrate  into  the  cavity ;  the  patient  should 
then  rest  for  a  day. 

Rigidity  of  the  cervix  may  be  the  consequence  of  long-standing 
continuous  congestion,  or  of  indurated  metritis.  It  should  be  treated 
successively  by  antiphlogistics,  glycerine,  alkalines,  and  resolvents 
capable  of  softening  the  uterine  tissue,  then  by  sponge  tents  and 
scarifications,  ignipuncture  and,  lastly,  by  division  and,  if  necessary,  by 
section  of  a  pyramidal  fragment  of  the  tissue  of  one  of  the  lips.  Or- 
ganic alterations,  fibroids,  polypi  and  cancer,  although  not  necessarily 
causes  of  sterility  (I  have  mentioned  cases  of  pregnancy  in  all  these 
cases),  considerably  hinder  the  uterine  functions,  preventing  in  most 
cases  the  contact  of  the  sperm  with  the  ovum,  or  uterine  pregnancy, 
or  the  continuation  of  a  pregnancy  beyond  a  few  weeks. 

Lastly,  abundant  or  abnormal  secretions  may  prevent  conception  in 
two  ways  :  mechanically  or  chemically.  By  a  purely  mechanical  action 
an  abundant  leucorrhoea  filling  the  uterus  (even  without  going  so  far 
as  to   form  hydrometria  and  pneumatosis),  or  a   viscous,  coherent, 


STERILITY  799 

tenacious  leucorrhoea,  completely  obstructing  the  cervix  by  a  gela- 
tinous plug  (analogous  to  that  of  pregnancy)^  make  conception  very 
difficult,  either  by  preventing  the  semen  from  penetrating  into  the 
uterine  cavity  or  by  expelling  the  sperm  (supposing  it  has  penetrated) 
by  their  abundance  and  the  uterine  contractions  which  impel  them 
naturally  towards  the  vagina.^  Chemically,  the  abnormal  secretions  of 
the  utero-vaginal  fluid  (from  the  mucus  of  the  womb  being  too  alka- 
line or  from  that  of  the  vagina  being  too  acid)  may  kill  the  sperma- 
tozoa.^ It  is  probable  that  the  latter,  unless  very  abundant  and  very 
acid,  has  not  much  action  on  the  mass  of  the  ejaculation,  the  central 
portion  of  which  it  can  hardly  reach ;  but  it  is  probable  that  the 
former  has  an  injurious  influence  on  the  relatively  small  quantity  which 
penetrates  into  the  uterine  cavity.^  In  a  number  of  cases  the  abund- 
ance of  the  leucorrhoea  and  even  its  purulence  does  not  prevent  con- 
ception. 

Tubal  maladies  cause  sterility  by  preventing  the  ovum  from  being 
received  and  the  sperm  from  being  transported  by  these  canals,  or 
both  these  elements  from  coming  into  contact  and  from  undergoing 
the  reciprocal  influence  known  as  fecundation.  They  may  exist  either 
without  or  within  these  organs. 

3.  Physiological  obstacles  to  conception. — They  depend  on  con- 
genital or  acquired  physiological  imperfection  or  on  functional  dis- 
order caused  by  some  morbid  state.  With  regard  to  disorder  of  the 
normal  i)hysioJogical  act,  it  may  either  be  one  of  defect  or  excess.  1 
have  already  mentioned  the  conditions  of  erection,  general  muscular 
contraction  and  orgasm  in  which  the  genital  economy  of  woman  should 
be  at  the  time  of  periodical  dehiscence,  menstruation  and  coitus  ;  there 
is  no  doubt  that  the  divergence  of  the  uterine  walls,  and  the  dilatation 
of  its  cavities  produced  by  erection,  greatly  facilitate  the  entrance  of  the 
sperm.  It  is  easy  to  understand  that  defect  of  orgasm,  indicated  by 
the  absence  of  any  voluptuous  sensation,  suffices  to  prevent  erection 
and  consequently  the  bringing  into  play  of  utero-tubal  conditions 
equally  favorable  to  the  transport  of  the  ovum  and  to  that  of  the 
sperm.  We  do  not  know  all  the  conditions  connected  with  the  accom- 
plishment of  the  internal  acts  of  this  function ;  for  instance  it  has  been 
asserted  that  women  have  conceived  in  spite  of  themselves,  after  rape, 
or  unknown  to  themselves,  during  intoxication  and  sleep,  or  even  after 
intercourse  to  which  they  had  consented,  but  which  had  given  them 
no  pleasure.  Although  these  facts  can  only  be  received  with  reserve 
I  can  afhrm  that  I  have  known  women  who  not  only  have  never 
experienced  the  least  pleasure,  but  have  felt  positive  repugnance  for 
an  act  which  they  only  performed  from  duty,  and  yet  have  had  several 
pregnancies.     That  is  undoubtedly    because  vital    orgasm,  erect  io 

^  Jobert  de  Lamballe  published  a  work  on  dropsy  of  the  cervix  and  its  in- 
fluence on  conception  in  1843. 

"  Donne,  E.q^erlences  sur  les  animalcules  spermatiques  et  sur  quelqi.ies-unes 
des  causes  de  la  sterilite  de  lafemme  (Gaz.  'ined.,  1837).  It  should  be  remem- 
bered that  alkaline  fluids  excite  the  movements  and  prolong  the  life  of  sperma- 
tozoa. 

^  Joulin,  op.  cit.,  p.  162. 


800  UTEEINE  DISEASES  IN  DETAIL 

and  the  involuntary  movements  of  the  uterus  and  tubes  may  escape 
sensibility  and  perception,  and  may  be  produced  independently  of  all 
voluntary  participation,  and  of  all  voluptuous  feeling.  These  cases, 
however,  are  exceptional.  The  proof  of  this  is,  that  in  most  women 
the  voluptuous  sentiment  is  only  gradually  awakened,  as  if  by  the 
education  of  a  new  sense,  and  that  in  such  cases  conception  only 
occurs  some  time  after  marriage.  According  to  Spencer  Wells,  out 
of  seven  fertile  marriages  delivery  only  occurs  four  times  before 
eighteen  months. 

When  alteration  of  the  physiological  acts  which  influence  impreg- 
nation depends  on  a  definite  morhicl  condition  it  is  easier  to  seize  the 
indications  and  to  apply  an  appropriate  treatment.  These  morbid 
states,  or  rather  the  general  affections  which  keep  them  up  (inflam- 
mation, rheumatism,  scrofula,  herpetism,  &c.),  usually  cause  sterility 
on  account  of  the  material  alterations  which  they  eff'ect  in  the  tissues 
of  the  internal  sexual  organs,  such  as  tumefaction,  ulceration,  &c., 
or  from  alterations  of  secretion,  such  as  leucorrhoea,  or  from  haemor- 
rhage.^ These  morbid  states  often  produce  functional  disorder, 
amenorrhoea,  dysmenorrhoea,  pains,  absence  of  desire,  ko,.;  hence  the 
repugnance  which  a  number  of  women  affected  with  uterine  disease 
experience  for  coitus. 

III.  Inaptitude  for  germination  or  ovulation. — This  is  the  most 
certain  cause  of  sterility  strictly  speaking ;  for  inaptitude  for  fecun- 
dation (whether  for  the  transport  and  union  of  germs  or  for  the 
reception  of  the  semen)  is  only  an  accident  preventing  the  evolution  or 
development  of  the  germ,  but  in  nowise  affecting  aptitude  for  repro- 
duction. Ovulation  is  the  best  proof  that  a  woman  can  give  of  her 
aptitude  for  procreation.  If  the  ova  are  formed  normally  in  the  ovary, 
if  they  reacli  their  maturity  there  and  are  expelled  periodically,  the 
woman  furnishes  the  reproductive  element  peculiar  to  her,  and  thereby 
gives  the  best  proof  of  reproductive  capacity.  If  this  physiological  act 
cannot  be  established,  or  is  suspended,  or  extinct,  the  woman  becomes 
sterile.  Sterility  in  such  a  case  is  often  permanent ;  it  may  however 
be  relative  or  temporary  :  the  former  depends  on  the  absence  of  the 
reproductive  organ,  on  defective  development,  atrophy,  or  on  an  organic 
alteration  or  disorganisation  of  the  ovary ;  the  latter  on  the  suspension 
of  the  reproductive  function  of  this  organ  under  the  influence  of  a 
local  pathological  state,  of  a  more  or  less  considerable  partial  degenera- 
tion of  its  tissue,  or  else  on  the  reaction  which  it  experiences  from  a 
general  morbid  affection,  from  the  debilitating  influence  which  is 
exercised  upon  it  by  a  serious  disorder  of  the  health  and  con- 
stitution. 

Me7tstruation  in  its  relations  tvith  sterility. — The  causes  of  sterility 
which  I  have  just  rapidly  reviewed  are  really  so  numerous  that,  in  order 
to  diagnose  them,  it  is  necessary  to  follow  an  artificial  method  based  on 

■>  Menon-hagia  is  particularly  formidable  on  account  of  its  tendency  to_  be 
reproduced  when  the  ovum  is  newly  fertilised,  in  which  case  there  is  abortion. 
In  these  instances  sterility  does  not  arise  from  defective  conception  but  fi-om 
some  inpediment  to  gestation. 


STEEILITY  801 

the  alterations  which  the  most  apparent  sexual  phenomenon^  menstrua- 
tion, may  undergo.  We  should  therefore,  first  of  all,  ask  a  sterile 
woman  whether  this  function  is  absent,  anomalous,  or  regular. 

Absence  of  menstruation  may  depend  on  congenital  absence,  atrophy, 
arrest  of  development,  or  imperfection  of  some  portions  of  the  sexual 
economy,  or  on  accidental  lesions,  suppuration,  gangrene,  adhesions, 
or  obliterations  of  the  same  parts.  The  prognosis  is  almost  always 
serious  as  regards  the  fertility  of  the  woman ;  except  in  slight  uterine 
atrophy  there  is  hardly  anything  to  hope  from  treatment.  Absence  of 
menstruation  may  be  associated,  although  rarely,  with  normal  con- 
formation of  the  genital  organs,  merely  constituting  a  physiological 
anomaly  or  imperfection,  as  is  proved  by  the  fact  that  women  who 
have  never  menstruated  have  had  children.  Ptondelet  and  Joubert^ 
have  both  published  cases;  the  former  of  a  woman,  who  had  twelve 
children,  the  latter  of  one  who  had  eighteen,  neither  of  whom  had  ever 
menstruated;  Colombat^  knew  another  who  had  a  child;  Tlechner^ 
speaks  of  a  woman  in  similar  conditions  having  had  six  pregnancies  in 
thirteen  years ;  Barbieri,^  Bruck^  and  Elsasser  have  each  seen  a  case 
of  the  same  kind.  Stark's^  work  on  this  subject  should  be  consulted. 
It  must  however,  be  admitted  that  the  physiological  absence  of 
menstruation  is  usually  accompanied  by  sterility,  and  it  is  not  certain 
whether  it  does  not  sometimes  depend  on  a  serious  disorder,  not  only  of 
the  function  but  of  the  sexual  economy.  Therefore  when  consulted 
about  a  case  of  this  kind,  we  cannot  be  too  careful  in  giving  an 
opinion,  which  cannot  be  based  on  a  complete  examination  of  organs 
inaccessible  to  our  investigations. 

Anomalies  of  menstruation  are  produced  either  by  mechanical  causes 
or  morbid  states.  The  former  are  manifested  under  the  form  of 
menstrual  retention,  deviated  menstruation,  dysmenorrhoea,  &c. ;  the 
physician  should  discover  the  congenital  or  acquired  origin  and  the 
superficial  or  internal  seat  of  the  obstacle  to  the  free  discharge  of 
blood.  The  latter  include  amenorrhcea,  leucorrhoea,  dysmenorrhoea, 
menorrhagia,  &c. ;  it  is  important  to  know  whether  they  depend 
on  a  merely  local  or  a  general  condition,  whether  there  is  disease 
of  the  uterine  mucous  membrane,  deviation  or  flexion  of  the  womb, 
active  or  passive  congestion,  &c. ;  or  whether  the  patient  is  suf- 
fering from  chlorosis,  anaemia,  plethora,  organic  disorders,  scrofula, 
constitutional  syphilis,  or  any  other  diathesis.  As  these  maladies 
do  not  always  produce  menstrual  disorders,  they  ought  to  receive 
great  attention  when  they  do  so  and  they  then  indicate  the  neces- 
sity for  the  association  of  general  with  local  treatment.  There  is  one 
which  is  all  the  more  deserving  of  attention  because  apparently  it 
does  not  prevent  conception.     1  mean  menorrhagia  or  metrorrhagia ; 

'  Erreurs  populaires,  liv.  ii,  ch.  1. 

2  Op.  cit.,  p.  34. 

■^  Gaz.  mid.,  1841,  p.  91. 

"  Gaz.  med.,  1843,  p.  207. 

•"■  Allgem.  unedic.  central.  Zeitung,  1854,  No.  14. 

*  Des  grossesses  survenues  en  I'absence  de  la  menstruation,  Stark's  Arcliiv 

fur  die  Geburtshiilfe.  .Jena,  1787. 

6] 


802  UTEEINE    DISEASES    IN    DETAIL 

these  are  not  in  one  sense  absolute  causes  of  sterility,  because  when 
haemorrhage  is  arrested  conception  may  occur  (and  frequently  does)  ; 
but  from  their  tendency  to  be  reproduced  periodically,  or  under  the 
influence  of  the  slightest  provocation,  or  even  without  any  known 
cause,  they  expel  the  recently  impregnated  ovum,  causing  early 
abortion  and  recurring  so  frequently  as  to  be  equivalent  to  sterility. 

Lastly,  whilst  regularity  of  menstruation  cannot  coexist  with  certain 
malformations  and  organic  disorders,  or  even  with  certain  morbid 
conditions  just  described,  it  may  do  so  with  lesions  of  the  uterine 
economy,  with  diseases  of  the  neighbouring  organs,  or  with  general 
affections  which  cause  sterility. 

The  true  cause  of  sterility,  therefore,  must  be  sought  in  one  of  the 
conditions  just  enumerated.  If  it  cannot  be  so  explained,  it  would 
yet  be  unjustifiable  to  assume  the  existence  of  one  of  the  causes  hypo- 
theticaUy  suggested  by  investigators  of  this  subject,  such  as  defective 
sympathy  or  physiological  incompatibility  between  the  husband  and 
wife.  If  we  succeed  in  identifying  the  cause,  it  will  still  be  necessary 
to  act  with  great  caution  j  holding  out  only  moderate  hopes  to  those 
whom  we  expect  to  cure ;  while  we  abstain  from  disclosing  abruptly 
or  unnecessarily  to  others  the  fact  that  in  their  case  there  is  little 
ground  for  a  favorable  prognosis. 


INDEX 


Abdominal  tumours,  774 
Ablation  of  polypi,  229 

—  of  fibroids,  229 

Abortion,  influence  of,  on  uterine  disease, 
236 

Abrasion  of  uterine  fungous  growths, 
225 

Abscess,  pelvic,  v.  Peri-uterine  inflam- 
mation. 

—  peri-uterine,  556,  566 

Acid  nitrate  of  mercury  as   a   uterine 

caustic,  209 
Adenitis  and  angioleucltis,  peri-uterine,. 

537 
Age,  influence  of,  on  the  development  of 

uterine  disease,  238 
Amenorrhoea,  259 

—  symptomatic,  260 

—  idiopathic,  261 

—  sympathetic,  261 

—  psychical,  261 
Amputation  of  the  cervix  uteri,  387 
Anaemia,  symptomatic  of  uterine  disease, 

104 
Anatomical  characteristics  of  the  sexual 

system  in  woman  (variability  of),  3 
Anomalies  of  the  genital  apparatus,  65 

—  of  the  ovaries,  70 

—  of  the  tubes,  73 

—  of  the  uterus,  75 
Apoplectic  dysmenorrhoea,  323 
Appearance,  external,  of  abdomen  (signs 

of  uterine  disease  furnished  by), 
122 

Appendages,  inflammation  of,  v.  Peri- 
uterine inflammation. 

Arsenical  powder  of  Friar  Come,  210 

Arteries,  helicine,  of  uterus,  36,  47 

Ascent  of  uterus,  355 

Ascites,  uterine,  581 

Asthenia,  a  characteristic  of  certain 
uterine  diseases,  156 

Atresia,  vulval,  271,  274 

—  vaginal,  271,  275 

—  uterine,  271,  275 

—  congenital  (linperforation),  271 

—  accidental  (obliteration),  272 


Atrophy  of  the  womb,  620 

—  excentric,  620 

—  concentric,  621 
Auscultation,  a  means  of  diagnosis,  121 
Autoplasty,  gynaecological,  229 

—  after  amputation  of  cervix,  229 

—  of  cervical  orifice,  316 

Ballottement    in    diagnosis   of    uterine 

disease,  121 
Baths,  use  of,  in  the  treatment  of  uterine 

disease,  176 

—  hot,  176 

—  cold,  179 

—  medicated,  183 

Belts  in  the  treatment  of  uterine  diseases, 
190 

—  abdominal,  190 

—  Courty's,  for  methodic  compression, 

191 

—  hypogastric,  191 
Bleeding,  169 

Blisters  to  the  cervix,  190 

Cancer  of  the  uterus,  692 

—  diagnosis,  692 

—  subjective   signs,    local    symptoms, 

pain,  692 

—  haemorrhage,  693 

—  cauliflower  excrescence,  698 

—  distiactiou    between    scirrhus    and 

encephaloid,  700 

—  treatment,  702 
by  caustics,  703 

by   amputation    of    the    cervix, 

704 

by  ecrasement,  705 

by  excision,  707 

Cancroid,  v.  Cancer  of  the  uterus. 
Carbonic  acid,  application  of,  to  cervix, 

205 
Castration,  770 
Cataplasms  to  cervix,  202 
Catarrh,  uterine,  v.  Leucorrhcca. 

—  of  the  Graafian  foUlcles,  738 
Cauliflower  excrescence,  698 


804 


INDEX 


Causes,  predisposing,  of  uterine  diseases, 

234,  238 
Caustics,  liquid,  209 

—  acid,  209 

—  alkaline,  209 

—  solid,  209 

—  canquoin,  209 

—  Vienna  paste,  209 

—  chloride  of  zinc,  210 

—  Friar  Gome's  arsenical  powder,  210 

—  nitrate  of  silver,  210 
Cauteries,  211 

—  gas,  215 

—  galvanic,  216 

—  Paquelin's  thermo-cautery,  216 
Cauterisation  of  the  cervix,  208 

—  —  by  potential  cautery,  209 

—  —  by  actual  cautery,  211 

—  —  by  ignipuncture,  211 
by  gas,  215 

—  —  by  electrolysis,  216 

—  of  uterine  cavity,  218 

by  intra-uterine  injections,  219 

—  —  by  nitrate  of  silver  crayon,  221 
Cavity,  pelvic,  division  of,  24 

—  uterine  (means  of   exploration  of), 

147 

Celibacy,  influence  of,  on  uterine  diseases, 
238 

Cellular  tissue  of  broad  ligaments,  26 

Cellulitis,  pelvic,  v.  Peri-uterine  inflam- 
mation. 

Cervix  uteri,  28,  32,  40 

—  anomalies  of,  80 
Changes  of  position,  343 

—  of  the  rectum,  due  to  development 

producing  changes  of  situation  in 
the  uterus  (Freund),  345 

—  displacements,  346 

—  deviations,  388 

—  flexions,  407 

—  inversion,  441 
Characteristics,  general,   of  uterine  dis- 
eases, 233 

—  their  frequency,  233 

—  preponderating  influence  of  predis- 

posing causes,  233 

—  their  double  nature,  general  or  dia- 

thetic and  local,  246 

—  their  chrouicity,  249 

—  difiiculty  of  cure,  250 

—  diversity,  251 

Chlorate  of  potassium,  its  use  in  mem- 
branous dysmenorrhoea,  330 

Chloride  of  zinc  for  cauterisation  of 
uterus,  210 

Chloroform,  vaginal  injections  of,  206 

Chlorosis,  symptomatic  of  uterine  dis- 
eases, 104 

Chronicity  of  uterine  maladies,  157, 
249 

Cicatrisation  after  cauterisation,  applica- 
tions for  hastening,  218 

Classification  of  uterine  diseases,  253 


Climate   in   the    treatment    of    uterine 

diseases,  169 
Cloaca,  58 

Collodion,  painting  the  cervix  with,  203 
Colpodesmoraphy,  382 
Colporaphy,  383 

Complexity  of  uterine  diseases,  252 
Complications  as  a  source  of  indications 

in  treatment,  160 

—  of  uterine  diseases,  248 
Congestion,  uterine,  466 

phvsiological   and   pathological, 

466 

—  —  idiopathic  and  symptomatic,  466 
active  and  passive,  467 

anatomical  changes  consequent 

on,  467 

diagnosis,  467 

subjective  signs,  467 

objective  signs,  468 

—  —  treatment,  469 

—  peri-uterine,  v.  Peri-uterine  inflam- 

mation. 

Constipation,  its  disastrous  effects  (co- 
pr^mia),  105,  106 

Constitution,  influence  of  the,  upon  the 
development  of  uterine  diseases, 
239 

Contusions  of  the  uterus,  v.  Traumatism. 

Copreemia,  106 

Corpus  luteura,  9 

Cough,  uterine,  102 

Cupping  in  uterine  diseases,  170,  173, 
226 

Cura  famis,  186 

Cure,  spontaneous,  rare  in  uterine  dis- 
eases, 151,  250 

Curette,  Recaraier's,  225 

—  Sims's,  225 

—  buttonhook,  225 

—  Courty's,  226 
Curvature  of  the  uterus,  409 
Cysts  of  the  ovary,  733 

—  —  composition,  734 
unilocular,  734 

—  —  multiple  or  multilocular,  734 
compound,  736 

origin  and  development,  738 

in  the  newly  born,  739,  noie 

in  the  married  and  single,  739 

—  —  duration,  742 

—  —  termination,  742 

—  —  deterioration    of  health,  fades 

ovariana,  743 

treatment,  749 

ovariotomy,  753 

—  tubo-ovarian,  780 

—  hydatid,  782 

Depots  laiteux,  556 

Descent  of  uterus,  v.  Prolapsus. 

Deviation  of  the  menses,  292 

—  diagnosis,  293 

—  treatment,  298 


INDEX 


805 


Deviations,  388 

—  three  degrees,  388 

—  anteversion,  retroversion,  and  latero- 

version,  388 

Diagnosis  of  uterine  diseases  in  general, 
96 

Diathesis,  influence  of,  on  the  develop- 
ment of  uterine  diseases,  240 

Digestion,  disorders  of,  99 

Dilatation  in  stenosis  of  the  cervix,  309 

—  by  dilating  instruments,  sounds  and 

bougies,  309 

—  by  sponge  tents,  310 

—  by  incision,  310 

Dilator,  uterine,  of  Lemenant-Deschenais, 
147 

of  Mathieu,  147 

of  Busch  and  Huguier,  147 

of  Aussandon,  148 

intra-uterine  pessary,  148 

Diseases  of  the  appendages,  714 
Dispareunia,  110 
Displacements,  346 

—  of  the  ovaries,  346 

—  of  the  Fallopian  tube,  348 

—  of  the  uterus,  344 
(hernia),  351 

horizontal  displacements,  354 

—  —  ascent,  355 
descent,  356 

Diversity  of  uterine  diseases,  251 

Division  of  cervix,  227,  311 

Double    character    of    uterine    diseases, 

diathetic  and  local,  246 
Douglas,  folds  of,  pouch  of,  23,  24 
Dropsy  of  the  uterus,  581 

—  encysted  of  the  ovary,  733 

—  profluent  of  the  tubes,  780 
Dysmenorrhcea,  300 

—  idiopathic,  301 

—  congestive,  302 

—  ovarian,  302 

—  treatment,  303,  309,  328 

—  mechanical,  305 

—  obstructive,  305 

—  dilatation  of  cervix,  309 

—  incision  of  cervix,  310 

—  division  of  cervix  by  elastic  ligature, 

315 

—  autoplasty,  316 

—  membranous,  319 

—  villous,  322 

—  apoplectic,  323 

Ectropion  of  the  cervix,  441 
Electricity,  use  of,  184 
Elytrnrapby,  383 

Emaciation  symptomatic  of  uterine  dis- 
eases, 104 
Eucephaloid  of  uterus,  v.  Cancer. 
Endometritis,  477 

—  exfoliative,  323,  note 
Engorgement,  uterine,  472 


Engorge-.nent,  uterine,  anatomical  cha- 
racters and  definition,  472 

—  —  diagnosis,  473 
treatment,  474 

Episio-perineoraphy,  381 

Episioraphy,  380 

Epispastics  in  treatment  of  uterine  dis- 
eases, 189 

Epithelioma  of  uterus,  v.  Cancer  of 
uterus. 

Erectility  of  uterus,  47 

—  of  the  ovary,  48 

—  erection  produced  artificially  on  the 

cadaver,  48 

—  absence  of  erectility  in  vagina  and 

Fallopian  tube,  48 

—  of  bulbs  of  the  vagina  and  of  the 

clitoris,  49 

—  connection    between    utero-ovarian 

erection  and  coitus,  ovulation  and 
menstruation,  49 
Eruptions  on  the  cervix  uteri,  v.  Ulcera- 
tions. 

—  different    forms,    as    in    cutaneous 

diseases,  635 
Evacuants  in  the  treatment  of  uterine 

diseases,  174 
Eversion  of  the  cervix,  441 
Examination,   complementary   means  of 

external,  120 

—  percussion,  120 

—  fluctuation,  121 

—  ballottement,  121 

—  change  of  posture,  121 

—  auscultation,  121 

—  external    appearance    of    abdomen, 

122 

—  exploratory  puncture,  122 

—  tapping,  122 

Exercise  in  the  treatment  of  uterine 
diseases,  167 

Exfoliation  of  the  uterine  mucous  mem- 
brane, 319 

Exfoliative  endometritis;  323,  note 

Exometritis,  puerperal,  503 

Exploration  of  the  uterine  cavity  (com- 
plementary means),  147 

Extirpation  of  normal  ovaries  (Battey's 
operation),  770 

Extra-uterine  pregnancy,  783 

—  differential  diagnosis,  783 

—  treatment,  785 

Exutories  in  the  treatment  of  uterine 
diseases,  189 

Fades  ovariana,  743 

—  uferina,  105 
Fallopian  tube,  13 

—  development  of,  56 

—  anomalies  of,  73 

—  hernia  of,  348 

—  inflani Illation  of,  526 

—  and  ovary,  inflammaLion  of,  530 
— '  tumours  of,  778 


806 


INDEX 


False  conceptious,  v.  Moles. 
Fibroids,  v.  Fibrous  tumours. 
Fibromata,  v.  Fibrous  tumours. 
Fibrous  tumours  of  the  uterus,  648 

—  interstitial,  649,  657 

—  sub-mucous,  649,  658 

—  sub-peritoneal,  649,  659 

—  tbeir    influence     upon     conception, 

pregnancy  and  delivery,  654 

—  influence  of  pregnancy  upon,  655 

—  diagnosis,  655 

—  prognosis,  664 

—  medical  treatment,  665 

—  surgical  treatment,  667 

—  hysterectomy,  668 

—  treatment  of,  during  pregnancy,  671 
delivery,  671 

Fistulse,  congenital,  61 
Flexions  of  the  uterus,  407 

—  congenital,  407 

—  accidental,  407 

—  simple,  408 

—  complicated,  408 

—  seat  of,  408 

—  degree  of,  409 

—  curvature,  409 

—  diagnosis,  417 

—  subjective  signs,  417 

—  common  symptoms,  418 

—  objective  signs,  419 

—  treatment,  420 

—  reduction,  421 

—  retention,  422 

—  mechanical  means  of  retention,  422 

—  flexion  of  the  cervix,  425 

—  anteflexion,  428 

—  retroflexion,  433 

—  lateroflexion,  431 

—  torsion,  431 

—  changes  in  the  uterine  tissue,  434 
Floating  tumours  of  the  abdomen,  782 
Fluctuation,    signs    of    uterine    disease 

furnished  by,  121 
Fluor  albus,  v.  Leucorrhoea. 
Fluxion,  461 

—  diagnosis,  462 

—  treatment,  463 

Fluxions,  methodical  treatment  of,   ap- 
plied to  uterine  diseases,  172 
Forceps,  Courty's,  201 

—  tenaculum,  208 
Frequency  of  uteriae  diseases,  233 

—  relative,  of  uterine  diseases,  255 
Functional  disorders,  257 
Fungosities,  uterine,  v.  Granulations. 

Gaertner's  canal,  57 

Galvanic  stem  pessary,  200 

Gas,  application  of,  to  cervix,  205 

—  —  carbonic  acid,  205 
apparatus  for,  206 

Gastrotomy,  772 

Genital  system  of  woman,  v.  System, 

Giraldes,  corpus  innominatum  of,  57 


Glycerine,  application  of,  to  cervix,  202 
Graaf,  De,  vesicles  ot^  5 
Granulations,  uteriue,  623 
predisposing  causes,  623 

—  —  influence  of  diathesis,  624 
varieties,  627 

treatment,  632 

Haemorrhage,  uterine,  334 

—  idiopathic,  335 

—  symptomatic,  335 

—  diagnosis,  336 

—  predisposing  causes,  336 

—  determining  causes,  337 

—  symptoms,  837 

—  treatment,  338 

—  hemostatics,  341 
Hsemorrhage,  pelvic,  714 

tubal,  715 

—  —  ovarian,  716 

from  the  utero-ovarian  plexus, 

717 

hsemorrbagiparous   pachyperito- 
nitis, 717 
Hematocele,  peri-uterine,  719 

—  retro-uterine,  719 

—  latero-uterine,  720 

—  ante-uterine,  720 

—  hematoma,  720 

—  modifications     undergone     by    the 

efl'used  blood,  721 

—  diagnosis,  722 

—  prognosis,  731 

—  treatment,  731 

—  puncture,  733 
Hermaphrodism,  true,  67 

—  lateral,  69 

—  vertical  or  double,  69 

—  transverse,  69 

—  coincides   with   imperfect    develop- 

ment, 69 

—  apparent,  70 

—  female,  70 

—  male,  70 
Hernia  of  uterus,  351 

during  pregnancy,  351 

—  —  of  the  linea  alba,  351 

of  the  unimpregnated  uterus,  352 

—  —  inguinal,  353 

crural,  353 

umbilical,  353 

ventral,  353 

diagnosis,  354 

—  —  treatment,  354 

—  of  the  ovary,  346 

—  —  inguinal,  347 

crural,  347 

ischiatic,  347 

—  —  umbilical,  347 

—  —  simple  and  double,  347 

congenital  (inguinal),  348 

accidental  (generally  crural),  348 

—  —  Fallopian  tube,  348 

—  diagnosis,  349 


INDEX 


807 


Hernia,  treatment,  350 

Hydatid  cysts,  782 

Hydrometria,  581 

Hydrorrhoea,  580 

Hydrotherapy  in  the  treatment  of  ute- 
rine disease,  179 

Hymen,  v.  Vulva. 

Hypertrophic  tendency  of  the  uterus, 
its  part  in  the  production  and 
cure  of  uterine  disease,  243,  244 

—  elongation  of  the  cervix,  370 
Hypertrophy,  uterine,  590 

—  —  common,  590 
special,  591 

—  —  essential,  591 

arrested  involution,  594 

—  partial,  of  cervix,  598 

—  —  subvaginal,  598 

—  —  supra-vaginal,  609 

limited  to  one  segment  or  to  one 

lip,  616 
Hysteralgia,  330 
Hysterectomy,  228 
Hysteria  symptomatic  of  uterine  disease, 

ioi 

Hysterocele,  351 

Hysteromata,  v.  Fibrous  tumours. 

Hysterotoine,  simple,  228,  311 

—  double,  228,  311 
Hysterotomy,  310 

—  Porro's  operation,  773 

Ice,  plugging  with,  203 

Idiometritis,  482 

Ignipuncture  of  the  cervix,  211 

Impotence,  788 

Inclination  of  the  uterus,  388 

Incurvation  of  the  uterus,  407 

Indications  to  fulfil  in  the  treatment  of 
uterine  diseases,  151 

Inertia,  uterine,  100 

Infarctus  (engorgement),  472 

Infecundity  or  inaptitude  for  impregna- 
tion, 791 

Inflammation,  necessity  of  subduing,  in 
the  treatment  of  uterine  diseases, 
156 

Inflammation,  the  only  contra-indication 
to  the  use  of  the  cautery,  217 

Inflexions  of  the  uterus,  407 

Infraction  of  the  uterus,  409 

Injections,  vaginal,  176 

—  intra-uterine,  219 

—  hot,  in  metrorrhagia,  341 
Injuries  of  the  uterus,  v.  Traumatism. 
Inversion,  uterine,  441 

its  different  degrees,  442 

—  —  incomplete  or  partial,  442 

complete  or  total,  442 

causes,  443 

—  —  mechanism,  445 

—  —  diagnosis,  subjective  signs,  445 

—  —  objective  signs,  446 

—  —  differential  diagnosis,  447 


Inversion,  uterine,  treatment,  477 
Involution  of  the  uterus,  arrest  of,  594 
subinvolution,  595 

—  —  superinvolution,  595 

diagnosis,  595 

subjective  signs,  596 

treatment,  596 

Irrigation,  vaginal,  178 

single  vaginal  irrigator,  178 

double  vaginal  irrigator,  178 

Irritable  uterus,  331 

Isthmus,  torsion  of  the,  309,  414 

Lactation,  neglect  of,  its  influence  on 
the  development  of  diseases,  237 

Laminaria  digitata  (tents  of)  for  dilata- 
tion of  the  cervix,  149 

Leiomyomata,  v.  Fibrous  tumours. 

Leucorrhcea,  569 

—  idiopathic,  573 

—  symptomatic,  575 

—  herpetic  or  dartrous,  575 

—  catarrhal,  scrofulous,  576 

—  vulval,  576 

—  vaginal,  576 

—  uterine,  576 

—  differential  diagnosis  of  the  different 

forms  of  infantile  leucorrhcea,  577 

—  hydrorrhoea,  580 

—  treatment,  582 
Ligaments  of  the  uterus,  20 

means  of  suspension,  20 

broad  ligaments,  20 

round  ligaments,  22 

utero-sacral,  23 

utero- vesical  adhesions,  23 

—  —  suspensory  ring,  23 

—  broad  (tumours  of),  780 

—  —  fibrous   tumours    and   myomata 

of,  780 

cysts  of,  781 

Ligature,    elastic,    for    section    of    the 

cervix,  315 
Lotion,  vaginal,  177 
Lymphatics  of  the  uterus,  36 

—  their  importance,  37 

Means  of  exploration  of  the  uterine 
cavity,  147 

—  intra-uterine  speculum,  148 

—  uterine  dilator,  148 
Mechanical  dysmenorrhcea,  305 
Medications  employed  in  the  treatment 

of  uterine  diseases,  161 

—  common,  162 

—  special,  163 
Membranous  dysmenorrhcea,  319 
Menorrhagia,  334 

Menstrual  disorders,  257 
Menstruation,  257 

—  its  influence  upon  uterine  disease, 

235 
Mensuration,  abdominal,  122 
Methods  of  treatment,  160 


808 


INDEX 


Methods  of  treatment,  generally  analyt- 
ical and  empirical,  161 
Metritis,  476 

—  pathological  anatomy,  476 

—  divisions,  480 

—  causes,  482 

—  course,  484 

—  subjective  signs,  486 

—  local  symptoms,  486 

—  general  symptoms,  487 

—  objective  signs,  489 

—  uterine  abscess,  493 

—  table  of  differential  diagnosis,  494 

—  treatment,  497 

of  complications,  501 

—  —  of  metrorrhagia,  501 
of  leucorrhcea,  &c.,  502 

—  puerperal,  503 

—  of  the  fundus,  506 

—  of  the  cervix,  506 

—  endometritis,  507 

—  parenchymatous  metritis,  508 

—  treatment,  509 
Metrorrhagia,  334 
Metrotome,  227 
Moles,  uterine,  686 

fleshy,  687 

vesicular  or  hydatidiform,  687 

diagnosis,  688 

treatment,  689 

Morbid  states  without  neoplasm,  461 
Mucous  membrane  of  the  uterus,  38 

—  of  the  fundus,  38 

—  its  tubular  glands,  39 

—  its  periodical  thickening,  40 

—  of  the  cervix,  40 

—  its  glands,  40 

—  Naboth's  eggs,  40 

—  mucus  of  the  uterus,  alkaline,  40 

—  uterine  (monthly  formation  of),  324 
Miiller's  ducts,  56 

—  their  separation,  58 

—  their  approximation,  58 

—  their  union,  58 

—  anomalies  of  development,  75 
Muscles  of  the  uterus,  40 

—  three  layers,  43 

—  their  continuity  with  the  muscular 

layers  of  the  tubes,  43 

—  their  connections  with  the  ovaries 

and  oviducts  by  the  muscular  layer 
of  the  broad  ligament,  45 
Myomata  of  the  uterus,  v.  Fibrous  tu- 
mours. 

Naboth's  eggs,  40 

Necessity  for  treating  uterine  maladies, 
151 

Neoplasms  (morbid  states  without),  460 

Nerves  of  the  uterus,  37 

Nervous  disorders,  100 

Neuralgia,  symptomatic  of  uterine  dis- 
eases, 101 

—  uterine,  330 


Nutrition,  disorders  of,  symptomatic  of 
uterine  disease,  104 

Obesity,  symptomatic  of  uterine  disease 

105 
Obliquity  of  the  uterus,  388 
Obliteration  of  the  vagina,  387 
(Edema,  acute  purulent  peri-uterine,  532 
Oophoritis,  510 
Ovaries,  anatomy  of,  4 

—  ectopia  of,  72,  346 

—  extirpation  of  (Battey's  operation), 

770 
Ovarioncia,  346 
Ovariotomy,  753 

—  indications  for,  754 

—  pregnancy  as  a  complication,  754 

—  contra-indications,  755 

—  preparatory  treatment,  756 

—  adhesions  as  coutra-indications,  756 

—  six  principal  stages  of  the  operation, 

757 

—  treatment  of  adhesions,  760 
— •  immediate  consequences,  765 

—  accidents,  766 

—  shock,  766 

—  exhaustion,  766 

—  haemorrhage,  767 

—  purulent  infection,  767 

—  antiseptic  precautions,  768 

—  remote  consequences,  769 
Ovaritis,  510 

Ovary,  cysts  of,  733 

—  solid  tumours  of,  774 
Oviducts,  13 

Ovisacs,  6 
Ovum,  8 

Pad,  perineal,  192 
Pain,  107 

—  symptomatic  of  uterine  diseases,  107 

—  spontaneous,  107 

—  caused  by  mode  of  decubitus,  108 

—  by  sitting,  108 

—  by  standing,  109 

—  by  movements  and  walking,  109 

—  by  coitus,  109 

—  by  tight  garments,  110 

—  elicited  artificially,  110 

—  by  movement,  110 

—  by  palpation,  110 

—  by  the  touch,  110 

—  three  principal  seats  of.  111 

—  iliac.  111 

—  lumbar.  111 

—  hypogastric,  112 

—  three  secondary  seats  of,  112 

—  anal,  112 

—  vaginal,  112 

—  pelvic,  112 

—  radiating,  112 

—  continuous,  113 

—  intermittent,  113 

Painting  the  cervix  with  collodion,  203 


INDEX 


809 


Palpation,  abdominal,  118 

—  rectal,  131 

Paralysis  symptomatic  of  uterine  disease, 
103 

Parametritis,  531.  v.  Peri-uterine  in- 
flammation. 

Parturition,  influence  of,  on  tlie  develop- 
ment of  uterine  disease,  236 

Pelvic  cavity,  division  of,  by  tbe  broad 
ligaments,  24 

—  peritonitis,  534.     v.  Peri-uterine  in- 

flammation. 

—  tumoui's,  774 
Perforation  of  the  hymen,  228 
Perimetritis,  531,  534 

Peritoneum,   sero-purulent  cysts  of  the, 

781 
Peritonitis,  peri-uterine,  534 
Peri-uterine  inflammation,  531 

—  adenitis  and  angioleucitis,  537 
Pessaries,  193 

Phlegmon  of  the  broad  ligament,  533 

—  peri-uterine,  535 
Physometria,  582 
Pneumatosis,  582 
Polypi  of  the  uterus,  673 

—  fibrous,  673 

—  mucous,  673 

—  vascular,  674 

—  diagnosis,  674 

—  treatment,  677 

Position  of  patient  for  operations,  207 
Posture,  signs  furnished  by  change  of, 

121 
Pregnancy,  in  relation  to  the  symptoms 

of  uterine  disease,  107 

—  influence  of,  on  the  development  of 

uterine  diseases,  236 

—  extra-uterine,  783 

—  —  diagnosis,  783 
treatment,  785 

modes  of  termination,  785 

Prolapsus  uteri,  356 

—  degrees  of,  356 

—  cystocele  and  rectocele,  359 

—  of  the  whole  uterus  or  of  the  cerviz 

only,  357 

—  anatomo- pathological      alterations, 

357 

—  causes,  360 

—  relaxation  of  suspensory  ligaments, 

361 

—  frequency,  362 

—  diagnosis,  363 

—  subjective  signs,  363 

—  objective  sii^ns,  366 

—  differential  diagnosis,  368 

—  treatment,  370 

—  hypertrophic  elongation  (prolapsus 

without  procidentia  of   the  fun- 
dus), 370 

—  reduction,  373 

—  retenticm,  374 

—  episioraphy,  380 


Prolapsus  uteri,  episio-perineoraphy,  381 

—  colpodesmoraphy,  382 

—  elytroraph}"^  or  colporaphy,  383 

—  obliteration  of  the  vagina,  387 

—  amputation  of  the  cervix,  387 
Prolapsus  of  uterus  without  descent  of 

the  fundus  (Virchow),  370 
Pruritus,  vulval,  118 
Puerperal  metritis,  503 
Puncture,  exploratory,  229 
Purgatives,  use  of,  174 

Rectal  palpation,  131 
Reduction  of  prolapsus,  373 

—  of  flexions,  420 

—  of  inversions,  449 

Regimen  as  a  means  of  treatment,  168 
Resolvents,  their  use,  184 
Retention  of  the  menses,  270 
Ring,  suspensory,  of  the  uterus,  23 
Rosenmiiller  (organ  of),  56 

Salpingitis,  526 

Scirrhus  of  uterus,  699,  701 

Sedatives  in  the  treatment  of    uterine 

diseases,  188 
Serous  membrane  of  uterus,  38 
Signs,  presumptive,  of  uterine  disease,  98 

—  furnished  by  direct  examination  of 

the  genital  organs,  118 
Situation  and  structure  of  the  uterus, 

influence   of,  on   development  of 

iiterine  disease,  234 
Sound,  uterine,  144 

—  —  its  use  as  a  means  of  diagnosis, 

144 

its  invention,  144 

mode  of  introducing,  145 

Speculum,  Fergusson's,  134 

—  trivalve,  134 

—  bivalve,  135 

—  quadrlvalve,  135 

—  Cusco's,  136 

—  Jobert's,  136 

—  Bozeman's,  137 

—  Sims's,  137 

Sponge  tents,  method  of  preparing,  148 

—  their  inti'oduction,  149 

—  exploration  of  uterus  after  dilatation 

by,  149 
Stenosis  of  cervix  uteri,  305 
Sterility,  787 

—  symptomatic  of  uterine  disease,  107 
Strangury,  uterine,  302 
Subinvolution,  595 
Superinvolution,  621 
Suppositories,  204 

Suspension,  means  of,  of  the  uterus,  20 

of  the  fundus,  20 

of  the  cervix,  23 

Suspensory  ring  of  the  uterus,  23 
Symptoms,  general,  of  uterine  disease,  98 

—  local,  of  uterine  disease,  105 

—  of  neighbourhood,  105 

52 


810 


INDEX 


Syringe,  uterine,  219 
System,  genital,  of  woman,  3 

its  constant  mutability,  3 

its  development,  55 

comparison  of,  with  male  genital 

system,  62 

teratology,  65 

Teratology  of  the  sexual  organs,  65 
Therapeutics     of     uterine     diseases    in 

genera],  96 
Thermocautery  of  Paquelin,  216 
Tonics    in    the     treatment    of    uterine 

diseases,  186 
Topical  applications  to  the  cervix,  203 
Torsion  of  the  isthmus,  309,  430 
Touch,  vaginal,  123 

—  rectal,  130 

—  vesical,  133 
Traumatisms  of  the  uterus,  483 
Treatment  of  uterine  diseases  in  general, 

151 
Tubercle  of  uterus,  689 
Tubo-ovaritis,  530 
Tumours,  fibrous,  of  uterus,  648 

—  of  the  annexes  and  pelvic  cavity,  774 

—  solid,  of  ovary,  774 

—  of  Fallopian  tubes,  778 

—  of  broad  ligaments,  780 

—  floating,  of  abdomen,  782 
Tympanitis,  uterine,  582 

Ulcer  of  pregnancy,  640 

—  of  uterine  catarrh,  640 

—  of  chronic  metritis,  641 

—  dartrous,  641 

—  scorbutic,  641 

—  scrofulous,  641 

—  syphilitic,  641 

—  cancerous,  642 


Ulcer  of  pregnancy,  rodent,  642 

—  diphtheritic,  643 

Ulceration  and  ulcers  of  the  cervix  uteri, 

634 
Urethra,  female,  65 
Urogenital  groove,  61 
Uterine  cough,  102 
Uterus,  16 

—  changes  in,  at  different  ages,  28 

—  structure  of,  36 

—  deficiens,  75 

—  unicornis,  75 

—  duplex,  didelphis,  76 

—  bicornis,  76 

—  cordiformis,  78 

—  globularis,  78 

—  septus,  bilocularis,  bipartitus,  79 

—  subseptus,  semipartitus,  79 

—  embryonic,  festal,  infantile,  79 

Vagina,  49 

—  absence  of,  86 

—  anomalies  of,  86 

—  double,  88 
Veins,  uterine,  36 
Versions  of  the  uterus,  388 

—  treatment  of,  397 

Vesical      irritation       symptomatic      of 

uterine  disease,  106 
Vesicles  of  De  Graaf,  6 
Villous  dysmenorrhoea,  322 
Vulva,  49 

—  glands  of,  53 

—  anomalies  of,  89 

—  absence  of,  89 
Vulval  pruritus,  118 

Waters,  mineral,  in  treatment  of  uterine 

disease,  182 
Wolffian  bodies,  55 


EEEATA. 

Page   79,  line  3rcl,/or  "  bipartitis,"  read  "  bipartitus." 
118,   „    12th,/or  "pruritis,"  >-ea(i  "pruritus." 

303,  note  2, /or  "  Philosophical,"  read  "  Obstetrical." 

304,  line  16th  from  bottom, /«•  "attractions,"  read  "  attractives." 
392,  note  Ijfor  "  nMario,"  read  "  Marion." 
498,  line  12th  from  bottom, /or  "  mauve,"  read  "  marshmallow." 
563,    „    ind,  for  "  is,"  read  "are." 
628,    „    2nd  from  bottom, /or  "  hysteralgia  uterine  colics,  and  "  read 

"  hysteralgia  and  uterine  colics." 
643,    „    18th  from  bottom,  for  "  abscess,"  read  "  abscesses." 


FEINTED   BT  J.   E.   ADI/AEB,   BAETHOLOMEW   CLOSE. 


UATALOGUE  NO.  1. 

CATALOGUE 


OF 


Medical,  Dental,  Pharmaceutical 


AND 


SCIENTIFIC  PUBLICATIONS, 


PUBLISHED    BY 


WITH 


CLASSIFIED 


LIST 


;----'-p:RESfLfiY  BLAKISTON    ■';..:l!l 
iPUBLlSHERiBOOKSEUER&iMPORTERf' 

medical.-dscientific  books.,! 


AND 


SUBJECT 


INDEX. 


I 


P.  BLAKISTON.  SON  &  CO.. 

(SUCCESSORS   TO    LINDSAY   &    BLAKISTON) 

1012   WALNUT    STREET, 
PHILADELPHIA. 


These  publications  may  be  had  through  Booksellers  in  all  the  principal  cities  of  the  United 
Statee  and  Canada,  or  any  book  will  be  sent,  postpaid,  by  the  publisher,  upon  receipt  of  price,  or 
will  be  forwarded  by  express  C.  O.  D.  upon  receiving  a  remittance  of  25  per  cent,  of  the  amount 
ordered  to  cover  express  charges. 


NOW  READY,  THE  SEVENTH  REVISED  EDITION. 

MEIGS  AND  PEPPER,  ON  CHILDREN. 

THE  MOST  THOROUGH,  COMPLETE  AND  PRACTICAL  WORK 
ON  THE  SUBJECT  NOW  BEFORE  THE  PROFESSION. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILD- 
REN. By  J.  Forsyth  Meigs,  m.d.,  one  of  the  Physicians  to  the  Pennsylvania' 
Hospital,  Consulting  Physician  to  the  Children's  Hospital,  etc.,  and  William 
Pepper,  m.d..  Professor  of  Clinical  Medicine,  University  of  Pennsylvania,  Provost 
and  ex-officio  President  of  the  Faculty,  Physician  to  the  Philadelphia  Hospital, 

Fellow  of  the  College  of  Physicians,  etc.,  etc.    The  Seventh  Revised  and  Improved 

Edition.     In  one  volume  of  over  i  loo  royal  octavo  pages. 

Price,  handsomely  bound  in  Cloth,  $6.00;  Leather,  $7.00. 

The  rapid  sale  of  six  large  editions  of  Drs.  Meigs  and  Pepper's  work  on  Children, 
and  the  demand  for  the  new  edition  now  ready,  is  sufficient  evidence  of  its  great 
popularity.  The  large  practice,  of  many  years*  standing,  of  the  authors,  imparts  to  it  a 
value  unequaled,  probably,  by  any  other  on  the  subject  now  before  the  profession. 

The  entire  work  has  been  now  again  subjected  to  an  entire  and  thorough  revision, 
some  articles  have  been  rewritten,  many  additions  made,  and  great  care  observed  by 
the  authors,  that  it  should  be  most  effectually  brought  up  to  the  light,  pathological 
and  therapeutical,  of  the  present  day. 

The  publishers  have  very  many  favorable  notices  of  the  previous  editions,  re- 
ceived from  numerous  sources,  foreign  and  domestic.  They  append  a  few  from  lead- 
ing journals,  which  will  give  a  general  idea  of  the  value  placed  upon  it,  both  as  a 
Text-Book  for  the  Student  and  a  work  of  reference  for  the  General  Practitioner. 

"  It  is  the  most  complete  work  upon  the  subject  in  our  language ;  it  contains  at  once  the  results  of  personal  and 
the  experience  of  others ;  its  quotations  from  the  most  recent  authorities,  both  at  home  and  abroad,  are  ample,  and 
we  think  the  authors  deserve  congratulations  for  having  produced  a  book  unequaled  for  the  use  of  the  student, 
and  indispensable  as  a  work  of  reference  for  the  practitioner." — American  Medical  journal. 


"  But  as  a  scientific  guide  in  the  diagnosis  and  treatment  of  the  diseases  of  children,  we  do  not  hesitate  to  say- 
that  we  have  seldom  met  with  a  text-book  so  complete,  so  just,  and  so  readable,  as  the  one  before  us,  which  in  its 
new  form  cannot  fail  to  make  friends  wherever  it  shall  go,  and  wherever  great  erudition,  practical  tact,  and  fluent 
and  agreeable  diction  are  appreciated." — American  yournal  of  Obstetrics. 


"  It  is  only  three  years  since  we  had  the  pleasure  of  recommending  the  Fifth  Edition  of  this  excellent  work. 
With  the  recent  additions  it  may  safely  be  pronounced  one  of  the  best  and  most  comprehensive  works  on  diseases 
of  children  of  which  the  American  Practitioner  can  avail  himself,  for  study  or  reference." — N.  Y.  Med.  yournal. 


"  It  is  not  necessary  to  say  much,  in  the  way  of  criticism,  of  a  work  so  well  known.  But  it  is  clinical.  Like  so 
many  other  good  American  medical  books,  it  marvelously  combines  a  risumi  of  all  the  best  European  literature 
and  practice,  with  evidence  throughout  of  good  personal  judgment,  knowledge,  and  experience.  The  book  also 
abounds  in  exposition  of  American  experience  and  observation  in  all  that  relates  to  the  diseases  of  children.  We 
are  glad  to  add  it  to  our  library.  There  are  few  diseases  of  children  which  it  does  not  treat  of  fully  and  wisely,  in 
the  light  of  the  latest  physiological,  pathological,  and  therapeutical  science." — London  Lancet. 

P.  BLAKISTON,  SON  &  CO.,  Publishers, 

Successors  to  LINDSAY  &  BLAKISTON, 

1012  WALNUT  STREET,  PHILADELPHIA. 


Philadelphia^  September  1st,  1882, 

Mr.  Presley  Blakiston  having  on  January  ist,  1882,  purchased  all  the 
interest  of  the  late  firm  of  Lindsay  &  Blakiston  will  continue  the  publication 
and  sale  of  Medical  and  Scientific  Books  at  No.  1012  Walnut  Street,  Phil- 
adelphia, having  associated  with  him  his  son,  Kenneth  M.  Blakiston,  and 
Frank  W.  Robinson,  under  the  firm-name  of 

P.  BLAKISTON,  SON  &  CO. 


MEDICAL,  DENTAL,  SCIENTIFIC 


AND 


PHARMACEUTICAL  BOOKS 


PUBLISHED    BY 


P.  BLAKISTON,  SON  &  CO.   PHILADELPHIA. 

4®=- Any  book  in  this  catalogue  can  be  had  from  or  through  booksellers  in  the  principal  cities  in 
the  United  States,  or  will  be  forwarded  free,  by  mail  or  express,  upon  receipt  of  the  price  by  the 
publisher. 


AMERICAN  HEALTH  PRIMERS. 

Edited  by  W.  W.  Keen,  m.d.     Complete  in  12  volumes,  handsomely  bound. 
Price,  in  cloth  binding,  50  cents  ;  paper  covers,  30  cents. 


I.  Hearing  and  How  to  Keep  It.    With  illus- 
trations.   By  Chas.  H.  Burnett,  m.d. 
II.  Long  Life,  and  How  to  Reach  It.     By  J.  G. 
Richardson,  m.d. 

III.  The  Summer  and  Its  Diseases.     By  Jas.  C. 

Wilson,  m.d. 

IV.  Eyesight,  and  How  to  Care  for  It.    With  il- 

lustrations. By  George  C.  Harlan,  m.d. 

V.  The  Throat  and  the  Voice.    With  illustrations. 

By  J.  Sons  Cohen,  m.d. 
VI.  The  Winter  and  Its  Dangers.    By  Hamilton 
Osgood,  m.d. 


VII. 


VIII. 


The  Mouth  and  the  Teeth.    With  illustra- 
tions.    By  J.  W.  White,  m.d.,  d.d.s. 
Brain  Work  and  Overwork.      By  H.   C. 
Wood,  Jr.,  m.d. 
IX.  Our  Homes.     With  illustrations.    By  Henrv 

Hartshornh,  m.d. 
X.  The  Skin  in  Health  and  Disease.    By  L.  D. 

BULKLEY,  M.D. 

XI,  Sea  Air  and   Sea  Bathing.     By  John  H. 
Packard,  m.d. 
XII.  School  and  Industrial  Hygiene.     By  D.  L. 
Lincoln,  m.d. 


"  In  their  practical  teachings,  learnins,  and  sound 
sense,  these  volumes  are  worthy  of  all  the  compli- 
ments they  have  received.  They  teach  what  every 
man  and  woman  should  know,  and  yet  what  nine- 
tenths  of  the  intelligent  class  are  ignorant  of,  or  at 
best,  have  but  a  smattering  knowledge  of" — Chicago 
Inter-Ocean. 


"  These  handbooks  of  practical  suggestion  deserve 
hearty  commendation.  They  arc  prepared  by  men 
whose  professional  competence  is  beyond  question, 
and  for  the  most  part,  by  those  who  nave  made  the 
subject  treated  the  specific  study  of  their  lives." — 
JVew  York  Sun. 


PRESLEY  B LA KIS TON'  S 


ACTON,  THE  REPRODUCTIVE  ORGANS. 

The  Functions  and  Disorders  of  the  Reproductive  Organs.  Their  Physio- 
logical, Moral,  and  Social  Relations.    By  Wm.  Acton,  m.r.c.s.      Sixth  Edition. 

Price  $2.50 

"In  the  work  now  before  us,  all  essential  detail  upon  its  subject  matter  is  clearly  and  scientifically  given.  We 
recommend  it  accordingly,  as  meeting  a  necessary  requisition  of  the  day,  refiasing  to  join  in  that  opinion  which 
regards  the  consideration  of  the  topics  in  question  as  beyond  the  duties  of  the  medical  practitioner." — The 
London  Lancet. 

ADAMS,  ON  CLUB  FOOT. 

Its  Causes,  Pathology  and  Treatment.  A  Revised  and  Enlarged  Edition. 
By  William  Adams,  f.r.c.S.  106  Wood  Engravings  and  six  Lithographic 
plates.     8vo.  Price  $5.00 

"  It  is  a  work  not  only  valuable  to  the  specialist,  but  should  be  read  bj'  every  practitioner  who  has  anything  to 
do  with  cases  of  club  foot." — Medical  Record. 

AGNEW,  ON  THE  PERINEUM  AND  FISTULA. 

Lacerations  of  the  Female  Perineum  and  Vesico-vaginal  Fistula.  Their  His- 
tory and  Treatment.  With  many  Illustrations.  By  D.  Hayes  Agxew,  m.d., 
Professor  of  Surgery,  University  of  Pennsylvania.     8vo.  Cloth,  Price  $1.25 

So  many  applications  having  been  made  for  these  papers,  as  originally  issued, 
the  author  has  thought  best,  after  a  thorough  revision,  to  place  them  before  the 
profession  in  book  form. 

AITKEN,  PRACTICE  OF  MEDICINE. 

The  Science  and  Practice  of  Medicine.  By  William  Aitken,  m.d.,  Edin- 
burgh. Third  American  from  Sixth  London  Edition,  greatly  enlarged,  re- 
modeled and  carefully  revised;  with  additions  by  Meredith  Clymer,  m.d., 
formerly  Professor  of  Practice,  University  of  New  York.  With  180  Illustrations 
and  large  colored  map,  showing  the  Geographical  Distribution  of  Disease. 
Large  8vo.     2  vols.  Price,  Cloth  $12.00. 

"  The  author  has  unquestionably  performed  a  service 
to  the  profession  of  the  most  valuable  kind."- Z'A^/'rair- 
titioner. 

"  It  would  be  difficult  to  point  out  anything  that  can- 
not be  found  in  Aitken." — Glasgovj  M-edical  yournal. 


"The  representative  book  of  Medical  science  and 
practice." — London  Lancet. 

"  The  additions  that  have  been  made  by  the  Ameri- 
can Editor  are  copious  and  important." — Ainerican 
yournal  Medical  Science. 

ALLEN,  COMMERCIAL  ORGANIC  ANALYSIS. 

An  Introduction  to  the  Practice  of  Commercial  Organic  Analysis.     By  Alfred 
H.  Allen,  f.c.s.    Vol.  i.     Cyanogen  Compounds,  Alcohols  and  their  Deriva- 
tives, Phenols,  Acids,  etc.     8vo.  Price  $3.50 
Vol.  H  now  ready.     8vo.  Price  $5.00 
Being  a  treatise  on  the  Properties,  Analytical  Examination,  and  Modes  of 
Assaying   the   various  Organic  Chemicals  and  Preparations  employed  in  the 
Arts,  Manufactures,  Medicine,  etc. 
ALLAN,  FEVER  NURSING. 

Notes  on  Fever  Nursing.     Addressed  to  nurses  in  hospital  and  private  life. 

By  James  W.  Allan,  M.D.     i2mo.     Illustrated.  Price  .75 

ALLINGHAM,  DISEASES  OF  THE  RECTUM.       Illustrated. 

Fistula,  Haemorrhoids,  Painful  Ulcer,  Stricture,  Prolapsus,  and  other  Diseases 

of  the   Rectum,  their  Diagnosis  and  Treatment.      By  William  Allingham, 

F.R.C.S.     Fourth  Edition,  enlarged.  Price,  Paper  covers,  .75  ;  Cloth,  $1.25 

Handsome   Edition,    London    Print,    Thick    Paper  and    Large   Type.      8vo. 

Cloth,  Price  $3.00 

"  No  book  on  this  special  subject  can  at  all  approach    I  "  It  is,  as  indeed  the  verdict  of  the  profession  has 

Mr.  Allingham's  in  precision,  clearness  and  practical  already  pronounced  it,  one  of  the  very  best  works  on 

good  sense." — London  Medical  Times  and  Gazette.        i  Disease?  of  the    Rectum." — Atnerican    yournal   of 

I  Medical  Science. 

ALTHAUS,  MEDICAL  ELECTRICITY. 

A  Treatise  on  Medical  Electricity,  Theoretical  and  Practical,  and  its  Use  in 
the  Treatment  of  Paralysis,  Neuralgia,  and  other  Diseases.  By  Julius  Althaus, 
M.D.     Third  Edition,  Enlarged.     246  Illustrations.     Svo.  Piice  $6.00 

In  revising  this  new  edition  the  author  has  carefully  brought  each  section  up 
with  the  latest  knowledge  of  the  subject. 


PUBLICA  TIONS.  5 


ANDERSON,  ON  ECZEMA. 

The  Pathology  and  Treatment  of  the  various  Eczematous  Affections  or  Erup- 
tions of  the  Skin.  By  McCall  Anderson,  m.d.  Third  Revised  and  Enlarged 
Edition.     8vo.  Price  $2.50 

ANSTIE,  STIMULANTS  AND  NARCOTICS. 

With  special  researches  on  the  Action  of  Alcohol,  Ether  and  Chloroform  on 
the  Vital  Organism.     By  Francis  E.  Anstie,  m.d.      8vo.  Price  $3.00 

"  He  is  an  original  worker  and  independent  thinker.  His  opinions  and  conclusions  are  valuable,  and  cannot 
be  neglected." — American  Medical  yournal. 

ATTHILL,  DISEASES  OF  WOMEN. 

Clinical  Lectures  on  Diseases  Peculiar  to  Women.  By  Lombe  Atthill,  m.d. 
5th  edition,  revised  and  enlarged,  with  numerous  illustrations.     i2mo.     Cloth. 

Price  $1.25 

"  It  is  the  concentrated  essence  of  the  knowledge  of  one  who  has  become  wise  by  reason  of  long  and  well- 
digested  experience  in  the  subjects  treated." — ATnerican  yournal  o/ Medical  Science. 
"  The  work  is  one  of  great  value  to  the  general  practitioner." — American  yournal  o/  Obstetrics. 

AVELING,  POSTURE  IN  OPERATIONS. 

The  Influence  of  Posture  on  Women  in  Gynecic  and  other  Operations.  By 
J.  H.  Aveling,  m.d.     Illustrated.     8vo.  Price  $2.00 

A  subject  which  hitherto  has  received  but  little  attention  is  here  treated  in  a 
very  thorough  manner,  showing  the  importance  of  certain  postures,  and  the 
various  diseases  produced  by  awkward  and  unhealthy  positions. 

BALFOUR,  ON  THE  HEART  AND  AORTA. 

Clinical  Lectures  on  Diseases  of  the  Heart  and  Aorta.  By  G.  W.  Balfour, 
M.D.     Illustrated.     2d  Edition.  {^Preparing: 

"  The  whole  work  reflects  much  credit  on  its  author,  and  firmly  establishes  his  reputation  as  an  authority  on  the 
important  diseases  of  which  he  treats." — Lo7idon  Practitioner. 

BARTH    AND    ROGER,    AUSCULTATION    AND    PERCUS- 
SION. 

A  Manual  for  the  Student.  By  M.  Barth  and  M.  Henri  Roger.  Trans- 
lated from  the  6th  French  Edition.     i2mo.  Price  $1.00 

BIBLE  HYGIENE; 

Or,  Health  Hints.  By  a  Physician.  This  book  has  been  written,  first,  to  im- 
part in  a  popular  and  condensed  form  the  elements  of  Hygiene  ;  second,  to  show 
how  varied  and  important  are  the  Health  Hints  contained  in  the  Bible,  and  third, 
to  prove  that  the  secondary  tendency  of  modern  Philosophy  runs  in  a  parallel 
direction  with  the  primary  light  of  the  Bible.     i2mo.        Paper,  .50;  Cloth,  $1.00 

"  The  scientific  treatment  of  the  subject  is  quite  abreast  of  the  present  day,  and  is  so  clear  and  free  from  unne- 
cessary technicalities  that  readers  of  all  classes  may  peruse  it  with  satisfaction  and  advantage." — Edinburgh 
Medical  yournal. 

BIDDLE,  MATERIA  MEDICA.      Ninth    Edition. 

Materia  Medica  for  the  Use  of  Students.  By  John  B.  Biddle,  m.d..  Late  Pro- 
fessor of  Materia  Medica  at  Jefferson  Medical  College,  Philadelphia.  8th 
edition.  Revised,  Enlarged  and  Illustrated.     8vo.  Price  $4.00 


"  The  additions  are  valuable,  and  we  must  congrat- 
ulate the  author  upon  having  improved  what  was 
already  so  useful  a  work,  both  to  the  student  and  phy- 
sician."— Phila.  Medical  and  Surgical  Reporter. 

"  It  has  been  the  design  of  the  author  to  present  in 


his  work  a  text-book  for  the  student.     It  is  brief,  and        '""■^■ 
yet  sufficiently  comprehensive.     His  style  is  clear  and 
yet  succinct.     He  covers   the  ground — covers  it  well, 
and  cumbers  his   work  with  nothing_  superfluous." — 


"  One  thing  that  particularly  recommends  this  work 
to  the  student  is,  that  the  book  is  not  so  large  as  to  dis- 
courage and  cause  him  to  feel  that  it  is  impossible  for 
him  to  get  over  it  and  so  much  else  in  the  short  time 
before  him." — St.  Louis  Medical  and  Surgical  your- 


Atlanta  Medical  arid  Surgical  yournal.  I     Canada  Lancet. 


It  contains,  in  a  condensed  form,  all  that  is  valu- 
able in  materia  medica,  and  furnishes  the  medical 
student  with  a  complete  manual  on  this  "subject."-^ 


PRESLEY  BLAKISTON'  S 


BLACK,  THE  REPRODUCTIVE  AND  RENAL  ORGANS. 

The  Functional  Diseases  of  the  Renal,  Urinary  and  Reproductive  Organs, 
with  a  General  View  of  Urinary  Pathology.  By  D.  Campbell  Black,  m.d., 
F.R.c.S.     i2mo.  Price,  Cloth,  ^1.25 

"  The  title  of  this  book  sufficiently  indicates  its  character  and  scope.  Some  of  the  chapters  are  almost  ex- 
haustive of  their  topics.  Thus,  in  the  chapter  on  spermatorrhoea,  the  whole  philosophy  and  therapeutics 
of  this  vexatious  condition  is  given  with  unusual  clearness." — Cincinnati  Lancet  and  Observer. 

BY    SAME   AUTHOR. 

DISEASES  OF  THE  KIDNEYS. 

Lectures  on  Bright's  Disease  of  the  Kidneys.  Delivered  at  the  Royal  Infirmary, 
Glasgow.     With  20  illustrations.     8vo. 

BLOXAM.  CHEMISTRY.Inorganic  and  Organic.  Fourth  Edition. 

With  Experiments,  By  Charles  L.  Bloxam,  Professor  of  Chemistry  in 
King's  College,  London,  and  in  the  Department  for  Artillery  Studies,  Wool- 
wich.    Fourth  edition.     With  nearly  300  Engravings.     8vo.  Price  ^4.00 

A  most  complete  Text-Book  for  Schools  and  Colleges. 

"  Professor  Bloxam  has  given  us  a  most  excellent  and  useful  practical  treatise.  His  666  pages  (now  700)  are 
crowded  with  facts  and  experiments,  nearly  all  well  chosen,  and  many  quite  new,  even  to  scientific  men  .  .  . 
It  is  astonishing  how  much  information  he  often  conveys  in  a  few  paragraphs.  We  might  quote  fifty  instances  of 
this." — Chemical  News. 

BLOXAM.     LABORATORY  TEACHING.     Fourth  Edition. 

Progressive  Exercises  in  Practical  Chemistry.  By  Charles  L.  Bloxam, 
Professor  of  Chemistry  in  King's  College,  London,  etc.  Fourth  edition.  With 
89  engravings.    i2mo.  Price  $1.75 

This  work  is  intended  for  use  in  the  Chemical  Laboratory,  by  those  who  are 
commencing  the  study  of  Practical  Chemistry.     It  contains : — 

I.  A  series  of  simple  Tables  for  the  analysis  of  unknown  substances  of  all 
kinds.  2.  A  brief  description  of  all  the  practically  important  single  substances 
likely  to  be  met  with  in  ordinary  analysis.  3.  Simple  directions  and  illustra- 
tions relating  to  Chemical  Manipulation.  4.  A  system  of  Tables  for  the  detec- 
tion of  unknown  substances  with  the  aid  of  the  Blowpipe.  5.  Short  instructions 
upon  the  purchase  and  preparation  of  the  tests  intended  for  those  who  have  not 
access  to  a  Laboratory. 

"  A  great  amount  of  valuable  practical  information  is  here  condensed  into  a  book  of  260  pages,  such  as  only  a 
practical  teacher  could  prepare." — New  England  journal  of  Education. 

BRUEN.     PHYSICAL  DIAGNOSIS.    Just  Ready. 

A  Pocket  Book  of  Physical  Diagnosis,  for  Physicians  and  Students.  By 
Edward  T.  Bruen,  m.d.,  Asst.  Prof,  of  Clinical  Medicine,  University  of  Penn'a. 
Illustrated  by  Original  Wood  Engravings.    i2mo.   Extra  Cloth.  Price  $2.00 

BENNETT.     NUTRITION  IN  HEALTH  AND  DISEASE. 

A  Contribution  to  Hygiene  and  Clinical  Medicine.  By  J.  Hexry  Ben- 
nett, m.d.     Third  Edition,  Revised  and  Enlarged.     Cloth.  Price  $2.50 

BY  SAME  Author. 

THE    TREATMENT    OF     PULMONARY     CONSUMPTION 
BY  HYGIENE,  CLIMATE  AND  MEDICINE. 

With  an  Appendix  on  the  Sanitaria  of  the  United  States,  Switzerland  and 
the  Balearic  Islands.     Third  Edition  much  Enlarged.  Price  $2.50 

"Any  physician  may  take  it  up  with  ever^'  feeling  of  confidence  that  the  views  enunciated  by  the  author  will  be 
found  to  be  able,  honest  and  orthodox." — Medico- Chirurgical  Review. 

BERKART,  ASTHMA. 

The  Pathology  and  Treatment  of  Asthma.  By  Joseph  B.  Berkart,  m.d. 
8vo.  Price  $2.50 


PUB  Lie  A  TIONS. 


BEALE  ON  SLIGHT  AILMENTS.     New  Edition.     Just  Ready. 

Slight  Ailments,  Their  Nature  and  Treatment.  By  Lionel  S.  Beale,  m.d., 
F.R.S.,  Professor  of  Practice,  King's  Medical  College,  London.  Second  Edition. 
Enlarged  and  Illustrated.  Price,  Cloth,  $1.25  ;   Paper  covers,  .75  cents. 

Fine  Edition,  Heavy  Paper.  Extra  Cloth,  Price  $1.75 

OUTLINE   OF   CONTENTS. 

Introductory.  The  Tongue  in  Health  and  Slight  Ailments.  Appetite.  Nausea.  Thirst.  Hunger.  Indigestion, 
its  Nature  and  Treatment.  Constipation,  its  Treatment.  Diarrhoea.  Vertigo.  Giddiness.  Biliousness.  Sick 
Headache.  Neuralgia.  Rheumatism.  The  Feverish  and  Inflammatory  State.  Of  the  Actual  Changes  in  Fever 
and  Inflammation.     Common  Forms  of  Slight  Inflammation,  etc.,  etc. 

"  We  venture  to  say  that  among  the  numerous  medical  publications  issued  during  iSSo,  there  has  been  none 
which  will  prove  more  useful  to  the  young  general  practitioner,  for  whom  it  is  really  intended,  than  this  volume, 
while  the  time  of  the  older  physician  might  be  much  more  unprofitably  spent." — American  yournal  of  Medical 
Science 

BY   SAME   AUTHOR. 

ON  LIFE  AND  VITAL  ACTION  IN  HEALTH  AND  DISEASE. 

i2mo.  Price  $2.00 

THE  USE  OF  THE  MICROSCOPE  IN  PRACTICAL  MEDI- 
CINE. 

For  Students  and  Practitioners,  with  full  directions  for  examining  the  various 
secretions,  etc.,  in  the  Microscope.  Fourth  Edition.  500  Illustrations.  Much 
enlarged.     8vo.  Pi-ice  $7.50 

"As  a  microscopical  observer,  and  a  histological 
manipulator,  his  (Dr.  Beale)  skill  and  eminence  are 
generally  conceded." — Popular  Science  Monthly. 


"  We  have  before  us  Prof.  Beale's  work,  T/ie  Micro- 
scope in  Medicine,  a  book  which  it  gives  us  pleasure  to 
recommend  to  every  student  of  microscopy,  whether  he 
be  a  physician  or  naturalist." — Journal  of  the  Frank- 
lin Institute,  Philadelphia. 

YLQ^N  TO  WORK  WITH  THE  MICROSCOPE. 

A  Complete  Manual  of  Microscopical  Manipulation,  containing  a  full  descrip- 
tion of  many  new  processes  of  investigation,  with  directions  for  examining  ob- 
jects under  the  highest  powers,  and  for  taking  photographs  of  microscopic 
objects.  Fifth  Edition.  Containing  over  400  Illustrations,  many  of  them  colored. 
Octavo.  Price  $7.50 

"The  Encyclopaedic  character  of  this  last  edition  of  Dr.  Beale's  well  known  work  on  the  Microscope  renders 
it  impossible  to  present  an  abstract  of  its  contents  ;  suffice  it  to  say,  that  anything  in  his  department  upon  which 
the  physican  can  desire  such  information  will  be  found  here,  and  much  more  in  addition.  It  is,  moreover,  a  store- 
house of  facts,  most  valuable  to  the  physician,  and  is  indispensable  to  every  one  who  uses  the  microscope." — 
Atnerican  yournal  of  Medical  Science. 

BIOPLASM. 

A  Contribution  to  the  Physiology  of  Life,  or  an  Introduction  to  the  Study  of 
Physiology  and  Medicine,  for  Students.     With  numerous  Illustrations. 

Price  $2.25 
PROTOPLASM;  or  MATTER  AND  LIFE. 

Third  Edition,  very  much  enlarged.     Nearly  350  pages.     Sixteen  Colored 

Plates.   Part  I.  DISSENTIENT.  Part  11.   Demonstrative.    Part  iii.  Suggestive. 

One  volume.  Price  ^3.00 

LIFE    THEORIES ;    Their  Influence   upon  Religious    Thought. 

Six  Colored  Plates.  Price  $2.00 

ONE  HUNDRED  URINARY  DEPOSITS, 

On  two  sheets,  for  the  Hospital,  Laboratory,  or  Surgery.  Each  Sheet  $1.00,  or 
on  Rollers,  Price  $1.25 

BERNAY,  CHEMISTRY. 

Notes  for  Students  in  Chemistry.  Compiled  from  Fowne's  and  other  manuals. 
By  Albert  J.  Bernay,  PH.D.     Sixth  Edition.     i2mo.  Price  {^1.25 

BOCK,  ANATOMY. 

An  Atlas  of  Human  Anatomy.  By  Prof.  C.  E.  BoCK,  of  Berlin.  Thirty-seven 
Colored  Plates,  containing  about  200  figures.    Quarto.    Half  Roan.    Price  $15.00 

This  is  one  of  if  not  the  best  Anatomical  Atlas  now  to  be  had,  and  its  produc- 
tion in  Germany  makes  it  certainly  the  cheapest. 


PRESLEY  BLAKISTON'  S 


BEASLEY.  THE  BOOK  OF  PRESCRIPTIONS. 

Containing  over  3100  Prescriptions,  collected  from  the  Practice  of  the  most 
Eminent  Physicians  and  Surgeons — English,  French  and  American ;  a  Com- 
pendious History  of  the  Materia  Medica,  Lists  of  the  Doses  of  all  Officinal  and 
Established  Preparations,  and  an  Index  of  Diseases  and  their  Remedies.  By 
Henry  Beasley.     Sixth  Edition,  Revised  and  Enlarged.  Price 

BY    SAME  AUTHOR. 

THE  DRUGGIST'S  GENERAL  RECEIPT-BOOK. 

Comprising  a  copious  Veterinary  Formulary;  numerous  Recipes  in  Patent 
and  Proprietary  Medicines,  Druggists'  Nostrums,  etc.;  Perfumery  and  Cos- 
metics; Beverages,  Dietetic  Articles  and  Condiments;  Trade  Chemicals,  Scien- 
tific Processes,  and  an  Appendix  of  Useful  Tables.    Eighth  Edition.    Price  $2.25 

THE  POCKET  FORMULARY  and  Synopsis  of  the  British  and 
Foreign  PharmacopcEias. 

Comprising  Standard  and  Approved  Formulae  for  the  Preparations  and  Com- 
pounds   Employed   in    Medical   Practice.      Tenth   Edition.     511    pp.      i8mo. 

Price  $2.25 

BENTLEY  AND  TRIMEN'S  MEDICINAL  PLANTS. 

A  New  Illustrated  Work,  containing  full  botanical  descriptions,  with  an  account 
of  the  properties  and  usesof  the  principal  plants  employed  in  medicine,  especial 
attention  being  paid  to  those  which  are  officinal  in  the  British  and  United  States 
Pharmacopoeias.  The  plants  which  supply  food  and  substances  required  by  the 
sick  and  convalescent  are  also  included.  By  R.  Bentley,  f.r.s..  Professor  of 
Botany,  King's  College,  London,  and  H.  Trimen,  m.b.,  f.h.s..  Department  of 
Botany,  British  Museum.  Each  species  illustrated  by  a  colored  plate  drawn 
from  nature.     In  Forty-two  parts.     Eight  colored  plates  in  each  part. 

Price  %2  each,  or  handsomely  bound  in  4  volumes.  Half  Morocco,  $90.00 

■  It  would  be  impossible   to   emimerate  all  the  new 


"  This  work  may  be  recommended  as  a  most  useful 
one  to  druggists,  and  all  who  desire  to  be  familiar 
with  the  Botany  of  Medicinal  Plants." — Druggists' 
Circular . 

"  The  work  when  complete  (it  is  now  complete) 
will  be  the  most  valuable  compend  of  Medical   Botany 


plants  that  are  here  delineated.  The  result  is  a  work 
which,  from  all  points  ofview,  isa  credit  to  the  scientific 
literature  of  the  day." — London  Lancet. 

"It  is  an  indispensable  work  of  reference  to  every  one 
interested  in  harmaceutical  Botany." — London  Fhar- 
maceutical  'j'  urnal.  \    ever  published." — Bosto'ii  journal  of  Chemistry 

BRADLZY,  ANATOMY. 

Comparative  Anatomy  and  Physiology.  By  S.  M.  Bradley,  f.r.c.s.  Sixty 
Illustrations.     Third  Edition.  Price  $2.00 

BRUNTON,  ACTION  OF  MEDICINES. 

Experimental  Investigation  of  the  Action  of  Medicines.  Part  I,  Circulation. 
By  T.  Lauder  Bruntox,  m.d.,  f.r.s.     Second  Edition.  [Preparing. 

BYFORD.     DISEASES  OF  WOMEN.     New  Revised  Edition. 

The  Practice  of  Medicine  and  Surgery,  as  applied  to  the  Diseases  of  Women, 
By  W.  H.  Byford,  a.m.,  m.d.,  Professor  of  Obstetrics  and  The  Diseases  of  Wo- 
men and  Children,  in  the  Chicago  Medical  College.  Third  Edition.  Revised 
and  Enlarged,  much  of  it  rewritten,    with  numerous  additional  illustrations. 

Price,  in  Cloth  $5.00;  Leather,  $6.00 


"The  treatise  is  as  complete  a  one  as  the  present 
state  of  our  science  will  admit  of  being  written.  We 
commend  it  to  the  diligent  study  of  every  practitioner 
and  student,  as  a  worlc  calculated  to  inculcate  sound 
principles  and  lead  to  enlightened  practice. — Nevj 
York  Medical  Record. 


"  The  author  is  an  experienced  writer,  an  able  teach- 
er in  his  department,  and  has  embodied  in  the  present 
work  the  results  of  a  wide  field  of  practical  obser\-a- 
tion.  We  have  not  had  time  to  read  its  pages  critically, 
but  freely  commend  it  to  all  our  readers,  as  one  of  the 
most  valuable  practical  works  issued  from  the  Ameri- 
can press." — Chicago  Medical  Examiner. 


BY    SAME   AUTHOR. 

ON  THE  UTERUS.     The  Chronic  Inflammation  and  Displace- 
ment of  the  Unimpregnated  Uterus. 

An  Enlarged  Edition,  with  Illustrations.     8vo,  Price  $2.50 

"A  good  book  from  a  good  man." — American  Journal  Medical  Science. 

"It  is  a  sensible,  practical  work,  and  cannot  fail  to  be  read  with  interest  and  profit."— fioj/o«  Medical  and 
Surgical  yournal. 


PUB  Lie  A  TIONS. 


BRAUNE,  TOPOGRAPHICAL  ANATOMY. 

An  Atlas  of  Topographical  Anatomy.  Thirty-four  Full-page  Plates,  Photo- 
graphed on  Stone,  from  Plane  Sections  of  Frozen  Bodies,  with  many  other  illus- 
trations. By  WiLHELM  Braune,  Professor  of  Anatomy  at  Leipzig.  Translated 
and  Edited  by  Edward  Bellamy,  f.r.c.s.,  Lecturer  on  Anatomy,  Charing 
Cross  Hospital,  London.     Quarto.     Price,  Cloth,    $8.00  ;  Half  Morocco,  $10.00 

"As  a  whole  the  work  cannot  fail  to  meet  with  a  hearty  reception  by  every  progressive  student  of  the  human 
body.  To  the  surgeon  it  is  a  contribution  to  the  study  of  topographical  anatomy  which  needs  to  be  known  to  be 
properly  appreciated  To  such  practitioners  who  reside  in  large  cities,  where  anatomy  can  be  studied  upon  the 
cadaver,  it  will  afford  a  valuable  aid,  while  to  those  who  are  without  such  means  of  study  it  is  an  almost  indis- 
pensable addition  to  a  working  library." — New  York  Medical  Record. 

"  We  commend  the  book  most  heartily  to  the  Profession." — American  Journal  ef  Medical  Scietice. 

BUCKNILL  AND  TUKE  ON  INSANITY. 

A  Manual  of  Pyschological  Medicine :  containing  the  Lunacy  Laws,  the 
Nosology,  (Etiology,  Statistics,  Description,  Diagnosis,  Pathology  (including 
morbid  Histology),  and  Treatment  of  Insanity.  By  John  Charles  Bucknill, 
M.D.,  F.R.S.,  and  Daniel  Hack  Tuke,  m.d.,  f.r.c.p.  Fourth  Edition,  much 
enlarged,  with  twelve  lithographic  plates,  and  numerous  illustrations.     Octavo. 

Price  $8.00 

"  We  have  read  no  book  in  any  language,  and  certainly  none  in  English,  which   ought  to  be  preferred  to    this 
for  a  text  book,  by  those  who  wish  to  make  a  thorough  study  of  the  subject. — Edinburgh  Medical  Journal. 
"  We  can  heartily  commend  the  work. — American  Journal  o/  Insanity. 

BURDETT,  HOSPITALS. 

Pay  Hospitals  and  Paying  Wards  throughout  the  World.  Facts  in  support 
of  a  rearrangement  of  the  system  of  Medical  Relief.  By  Henry  C.  Burdett. 
8vo.  Price  $2.25 

"  Mr.  Burdett  displays  and  discusses  the  whole  scheme  of  Hospital  ^rmmmnAat^nin  with  a  comprehensive 
understanding  of  its  nature  and  extent. — American  Practitioner. 

BY  SAME  AUTHOR. 

COTTAGE  HOSPITALS. 

General,  Fever,  and  Convalescent :  their  Progress,  Management,  and  Work. 
Second  Edition,  rewritten  and  much  Enlarged,  with  many  Plans  a-rd  Illustra- 
tions.    Crown  8vo.  Price  $4.50 

Contents. — Chap. — i.  Origin  and  Growth  of  the  Cottage  Hospital  System.  2.  Comparative  Success  of 
Treatment  in  large  and  small  Hospitals.  3.  Finance.  4.  Cottage  Hospital  Construction  and  Sanitary  Arrange- 
ments. 5.  The  Medical  and  Nursing  Departments.  6.  Domestic  Supervision  and  General  Management.  7. 
Cottage  Hospital  Appliances  and  Fittings.  8.  Cottage  Fever  Hospitals.  9.  Midwifery  in  Cottage  Hospitals.  10. 
Remunerative  Paying  Patients.  11.  Convalescent  Cottages .  12.  Cottage  Hospitals  in  America.  13.  Mortu- 
aries. 14.  A  more  Detailed  Account  of  certain  Cottage  Hospitals,  with  Plans  and  Elevations.  15.  Selected  and 
Model  Plans  criticised  and  compared,  with  a  detailed  description  of  various  Hospitals.  16.  Peculiarities  and 
Special  Features  in  the  Working  of  Cottage  Hospitals.  With  an  Appendix  containing  much  statistical  and  useful 
information. 

"  Mr.  Burdett's  book  contains  a  mass  of  information,  statistical,  financial,  architectural,  and  hygienic,  which  has 
already  proved  of  great  practical  utility  to  those  interested  in  cottage  hospitals,  and  we  can  confidently  recom- 
mend this  second  edition  to  all  who  are  in  search  of  the  kind  of  information  which  it  contains." — Lancet. 

BUZZARD,  NERVOUS  DISEASES. 

Clinical  Lectures  on  Diseases  of  the  Nervous  System.  By  Thos.  Buzzard, 
M.D.     Illustrated.     Octavo.  '  Price  $5.00 

CARPENTER,  THE  MICROSCOPE.     Sixth  Edition. 

The  Microscope  and  its  Revelations.  By  W.  B.  Carpenter,  m.d.,  f.r.s. 
Sixth  Edition.     Revised  and  Enlarged,  with  over  500  Illustrations.     Price  $5.50 


"  Not  only  the  student  of  medicine,  but  amateurs, 
and  others  interested  in  the  study  of  natural  history, 
will  find  this  volume  one  of  great  practical  value." — 
JWw/  York  Medical  Journal. 

"  It  is  by  far  the  most  complete  and  useful  treatjse 
now  accessible  to  the  student." — The  Technologist. 


"As  a  text  book  of  Microscopy  in  its  special  relation 
to  natural  history  and  general  science,  the  work  before 
us  stands  confessedly  first,  and  is  alone  sufficient  to 
supply  the  wants  of  the  ordinary  student." — American 
Journal  0/  Microscopy. 


PRESLEY  B LA KIS TON'S 


CARTER,  EYESIGHT.     New  Edition  now  ready. 

Eyesight,  Good  and  Bad.  A  Treatise  on  the  Exercise  and  Preservation  of 
Vision.  By  Robert  Brudenell  Carter,  f.r.c.s.  Second  Edition,  with  50 
Illustrations,  Test  Types,  etc.     i2mo.  Price,  Cloth,  $1.25 

"It  is  written  in  a  lucid  and  agreeable  style,  conveying  an  easily  comprehensible  account  of  the  structure  of 
the  eye  and  the  function  of  vision,  and  gives  a  description  of  the  principal  anomalies  of  the  latter,  at  the  same 
time  inculcating  such  salutary  advice  as  may  be  beneficial  for  the  preservation  of  sight." — London  Medical 
Times  and  Gazette. 

"  There  is  much  wholesome  advice  given  on  the  '  Care  of  the  Eyes  in  Infancy  and  Childhood,'  and  on  this 
account,  if  no  other,  the  book  should  be  in  the  hands  of  every  parent  and  teacher." — St.  Louis  Courier  of 
Medicine. 

CARTER,  PRACTICE  OF  MEDICINE. 

Elements  of  Practical  Medicine.  By  Alfred  H.  Carter,  m.d.,  London, 
Member  of  the  Royal  College  of  Physicians ;  Physician  to  the  Queen's  Hos- 
pital, Birmingham,  etc.     Crown  8vo.  Price  $3.00 

"  The  object  of  this  volume  is  to  provide  the  student  with  a  general  introduction  to  the  study  of  Medicine, 
and  to  bring  the  essentials  of  the  subject,  so  far  as  required  for  the  ordinary  medical  qualifications,  within  the 
grasp  of  those  who  have  not  the  time  or  leisure  to  read  the  larger  and  more  elaborate  works  on  Practice." — 
Pre/ace. 

"  Dr.  Carter  is  favorably  known  as  a  London  physician  of  learning  and  experience,  and  a  clear  writer.  He 
aims  to  give  a  judicial  epitome  of  practical  medicine,  and  this  is  a  well-prepared  book." — Philadelphia  Medi- 
cal and  Surgical  Reporter. 

CARSON,  THE  UNIVERSITY  OF  PENNSYLVANIA. 

A  History  of  the  Medical  Department  of  the  University  of  Pennsylvania  from 
its  foundation  in  1765,  with  sketches  of  deceased  Professors,  etc.  By  the  late 
Joseph  Carson,  m.d.    8vo.  Price  $2.00 

Originally  a  lecture  delivered  at  the  request  of  the  Faculty,  this  essay  has  grown 
into  an  important  Historical  work  of  the  College  and  its  promoters. 

CAZEAUX'S  GREAT  OBSTETRICAL  TEXT-BOOK. 

A  Theoretical  and  Practical  Treatise,  including  the  Diseases  of  Pregnancy 
and  Parturition.  By  P.  Cazeaux,  Adjunct  Professor  in  the  Faculty  of  Medi- 
cine of  Paris,  etc.  etc.  Revised  and  Annotated  by  S.  Tarnier,  Former  Clini- 
cal Chief  of  the  Lying-in-Hospital,  etc.,  etc.  Sixth  American  from  the  Seventh 
French  Edition.  Translated  by  Wm.  R.  Bullock,  m.d.  One  volume.  Royal 
Octavo,  over  iioo  pages,  with  Lithographic  and  175  other  Illustrations  on 
Wood.  Price,  Cloth,  ^6.00  ;  Leather,  $7.00 

M.  Cazeaux's  great  work  on  Obstetrics  has  become  classical  in  its  character,  and 
almost  an  Encyclopsedia  in  its  fulness.  Written  expressly  for  the  use  of  students  of 
medicine,  and  those  of  midwifery  especially,  its  teachings  are  plain  and  explicit, 
presenting  a  condensed  summary  of  the  leading  principles  established  by  the  masters 
of  the  obstetric  art,  and  such  clear,  practical  directions  for  the  management  of  the 
pregnant,  parturient,  and  puerperal  states,  as  have  been  sanctioned  by  the  most 
authoritative  practitioners,  and  confirmed  by  the  author's  own  experience.  Collect- 
ing his  materials  from  the  writings  of  the  entire  body  of  antecedent  writers,  carefully 
testing  their  correctness  and  value  by  his  own  daily  experience,  and  rejecting  all  such 
as  were  falsified  by  the  numerous  cases  brought  under  his  own  immediate  observa- 
tion, he  has  formed  out  of  them  a  body  of  doctrine,  and  a  system  of  practical  rules, 
which  he  illustrates  and  enforces  in  the  clearest  and  most  simple  manner  possible. 


"  The  edition  before  us  is  one  of  unquestionable  ex- 
cellence. Every  portion  of  it  has  undergone  a  thorough 
revision,  and  no  little  modification  ;  while  copious 
and  important  additions  have  been  made  to  nearly 
every  part  of  it.  It  is  well  and  beautifully  illustrated 
by  numerous  wood  and  lithographic  engravings,  and 
in  typographical  execution  will  bear  a  favorable  com- 
parison with  other  works  of  the  same  A3.%z." American 
Medical  journal. 

"  The  translation  of  Dr.  Bullock  is  remarkably  well 
done.  We  can  recommend  this  work  to  those  espe- 
cially interested  in  the  subject  treated,  and  can  espe- 
cially recommend  the  American  edition." — Medical 
Times  and  Gazette. 

"  We  do  not  hesitate  to  say  that  it  is  now  the  most 
complete  and  best  treatise  on  the  subject  in  the  Eng- 
lish language." — Buffalo  Medical  Joitrnal. 


"  It  is  unquestionably  a  work  of  the  highest  excel- 
lence, rich  in  information,  and  perhaps  fuller  in  details 
than  any  text-book  with  which  we  are  acquainted. 
The  author  has  not  merely  treated  of  every  question 
which  relates  to  the  business  of  parturition,  but  he  has 
done  so  with  judgment  and  ability." — British  and 
Foreign  Medico-  Chirurgical  Reziicw. 

"  No  work,  in  our  estimation,  bears  any  comparison 
to  Cazeaux,  in  its  entire  perfectness  ;  and  if  we  were 
called  upon  to  rely  alone  on  one  work  on  accouch- 
ments,  our  choice  would  fall  upon  the  book  before  us 
without  any  kind  of  hesitation." — West.  your,  of  Med- 
icine atid  Surgery. 

"  We  know  of  no  work  on  this  all-important  branch 
of  our  profession  that  we  can  commend  to  the  student 
or  practitioner  as  a  safe  guide  befcre  this." — Chicago 
Medical  Journal. 


PUBLICA  TIONS. 


CHARTERIS,  PRACTICE  OF  MEDICINE. 

Hand-Book  of  the  Practice  of  Medicine.  By  M.  Charteris,  m.d.,  Member 
of  Hospital  Staff  and  Professor  in  University  of  Glasgow.  With  Microscopic  and 
other  illustrations.  Price  $1.25 

"  We  have  not  often  met  with  a  book  whidi  can  be  so  confidently  recommended  to  physicians  or  men  in  general 
practice . ' ' — Lancet. 

"  The  style  in  which  it  is  writtea  is  clear  and  at-traetive.     The  illustrations  are  a  marked  feature  in  it.     It  can 
be  recommended  as  a  very  reliable,  handy  book,  well  adapted  for  ready  reference." — New  Remedies. 

CHAVASSE  ON  CHILDREN. 

The  Mental  Culture  and  Training  of  Children.     By  Pye  Henry  Chavasse. 

i2mo.  Price,  Paper  covers,  .50;  Cloth,  fii.oo 

The  mental  culture  and  training  of  children  is  of  immense  importance.     Many 

children  are  so  wretchedly  trained,  or  rather  not  trained  at  all,  and  so  mismanaged, 

that  a  few  thoughts  on  this  subject  cannot  be  thrown  away,  even  upon  the  most 

careful. 

CLAY  ON  OBSTETRIC  SURGERY.     Third  Edition. 

A  complete  Hand-Book  of  Obstetric  Surgery,  with  Rules  for  every  Emergency 
and  Descriptiens  of  the  more  difficult  as  well  as  the  every  day  operations.  By 
Charles  Clay,  m.d.,  with  numerous  illustrations.  From  the  Third  London  Edi- 
tion.    i2mo.  Price  $2.00 

"  It  is  a  useful  and  convenient  book  of  reference ;  the  illustrations  are  good,  and  the  book  will  be  found  of  value 
to  the  student  and  young  practitioner,  as  well  as  to  the  skilled  Obstetrician." — American  Journal  of  Obstetrics. 

CLEVELAND,  POCKET  DICTIONARY.  « 

A  Pronouncing  Medical  Lexicon,  containing  correct  Pronunciation  and  Defi- 
nition of  terms  used  in  medicine  and  the  collateral  sciences.  By  C.  H.  Cleve- 
land, m.d.     Twenty-ninth  Edition.     i6mo. 

Price,  Cloth,  75  cents  ;  Tucks  with  Pocket,  ^i.oo 
This  is  a  most  convenient  size  for  the  pocket,  and  contains  all  the  principal  words 
in  use,  together  with  rules  for  pronunciation,  abbreviations  used  in  prescriptions,  list 
of  poisons,  their  antidotes,  etc. 

COHEN,  INHALATION.     Enlarged  Edition. 

Inhalation,  its  Therapeutics  and  Practice,  including  a  Description  of  the  Ap- 
paratus Employed,  etc.  By  J.  Solis  Cohen,  m.d.  With  cases  and  Illustrations. 
A  New  Enlarged  Edition.     8vo.  Price  $2.50 

"  The  book  has  the  merit  of  containing  much  information  that  cannot  be  found  elsewhere." — N.  Y.  Medical 
yournal. 
"  One  of  the  best  treatises  we  have  seen  on  this  subject." — Medical  Times  and  Gazette. 

BY   SAME  AUTHOR. 

CROUP, 

In  its  Relation  to  Tracheotomy.     8vo.  Price  $1.00 

CLARKE,  SURGERY. 

Outlines  of  Surgery  and  Surgical  Pathology,  including  the  Diagnosis  and 
Treatment  of  Obscure  and  Urgent  Cases.  By  F,  LeGross  Clarke,  f.r.s. 
Second  Edition.     8vo.  Price  $2.00 

COBBOLD,  PARASITES. 

A  Treatise  on  the  Entozoa  of  Man  and  Animals,  including  some  account  of 
the  Ectozoa.  By  T.  Spencer  Cobbold,  m.d.,  f.r.s.  With  85  illustrations. 
8vo.  Price  $^.00 


PRESLEY  B LA KIS TON'S 


COLES,  THE  MOUTH.     Third  Edition,  just  ready. 

Deformities  of  the  Mouth,  Congenital  and  Acquired,  with  Their  Mechanical 
Treatment.  By  Oakley  Coles,  d.d.s.  Third  Edition.  83  Wood  Engravings 
and  96  Drawings  on  Stone.     8vo.  Price  $4.50 

"  Altogether  we  must  heartily  congratulate  Mr.  Coles  on  this  creditable  completion  of  a  work  which  cannot 
but  redound  to  his  credit  wherever  it  is  known." — British  yournal  of  Dental  Science. 
"  We  recommend  this  book  to  the  study  of  both  surgeons  and  dentists." — London  Lancet. 

BY   SAME   AUTHOR. 

A  MANUAL  OF  DENTAL  MECHANICS. 

Containing  much  information  of  a  practical  nature,  upon  the  Materials  and 
Appliances  used  in  Mechanical  Dentistry.  For  Practitioners  and  Students. 
Second  Edition,  with  140  Illustrations.     i2mo.  Price  $2.00 

THE  DENTAL  STUDENT'S  NOTE-BOOK. 

A  new  Edition.     i6mo.  Price  $1.00 

COLLIS,  ON  CANCER. 

The  Diagnosis  and  Treatment  of  Cancer  and  Tumors  Analogous  to  it.  By 
M.  H.  COLLIS,  M.D.     With  Colored  Plates.     Svo.  Price  $3.00 

CORMACK,  CLINICAL  STUDIES. 

Illustrated  by  Cases  Observed  in  Hospital  and  Private  Practice.  By  Sir 
John  Rose  Cormack,  m.d.,  k.b.,  etc.  Illustrated.  2  vols.  1,127  PP-  Price  I5.00 

Contents. — Vol.  i. — Chapter  l.  Relapsing  Fever,  ii.  Cholera,  iii.  Scarlatinous  Nephritis,  iv.  Puer- 
peral Convulsions,  v.  Glandular  Degeneration  of  the  Kidney  and  its  Relation  to  Scrofula,  vi.  Infantile  Re- 
mittent Fever,  vn!  Labor  Complicated  with  Cauliflower  Excrescence  of  the  Uterus,  viii.  Value  of  the 
Dark  Abdominal  Line  as  a  Test  of  Recent  Delivery,  ix.  Dystocia  from  Cystous  Kidney  in  the  Mature 
Fostus.     X.  Hernia  of  the  Uterus. 

Vol.  IT. — Chapter  i.  Air  in  the  Organs  of  Circulation,  ii.  Reflex  Convulsions  in  Infancy,  iii.  Pharj'ngo- 
Laryngo-Tracheal  Diphtheria,  rv.  Diphtheria,  v.  Paralytic  Affections,  vi.  Paralytic  AflFections  in  Enteric 
Fever,  vii.  Treatment  of  Paralytic  Affections,  viii.  Non-Venereal  Discharges  from  the  Urethra,  ix.  Scar- 
latinal Vaginitis.  x.  Congenital  Syphilis.  Xl.  Chronic  Poisoning  by  Chloroform,  xii.  Resection  of  the 
Shoulder-joint,  xiii.  Concussion  of  the  Brain,  xiv.  General  Paralysis  with  Insanity,  xv.  Short  Attacks 
of  Insanity. 

"  His  peculiar  opportunities  and  the  manner  in  I  "  The  work  will  make  one  of  valuable  reference 
which  he  has  availed  himself  of  them  give  these  upon  the  subjects  embraced  by  it,  many  of  which  have 
essays  a  value  of  their  own." — London  Practi-  been  treated  at  considerable  length." — American 
tioner.  I  Journal. 

CURLING,  ON  THE  TESTIS. 

A  Practical  Treatise  on  the  Diseases  of  the  Testis,  Spermatic  Cord,  and 
Scrotum.  By  T.  B.  Curling,  m.d.,  f.r.s.  Fourth  Edition,  Enlarged  and  Il- 
lustrated.    Svo.  Price  $5.50 

"  We  believe  this  work  to  be  the  most  trustworthy  that  can  be  consulted  in  this  Department  of  Surgery, 

his  pages  abound  with  valuable  suggestions  and  cautions   that  mark  his  intimate  knowledge  of  the 

subj  ect.' ' — London  Practitioner. 

COOPER'S  SURGICAL  DICTIONARY. 

A  Dictionary  of  Practical  Surgery  and  Encyclops:dia  of  Surgical  Science. 
By  Samuel  Cooper.  New  Edition,  brought  down  to  the  present  time.  By 
Samuel  A.  Lane,  f.r.c.s.,  assisted  by  various  eminent  Surgeons.  In  two 
vols.  Price  $12.00 

COTTLE,  ON  THE  HAIR. 

The  Hair  in  Health  and  Disease.  By  E.  W.  Cottle,  m.d.  Partly  from  the 
notes  of  the  late  George  Nayler.     iSmo.  Price  .75 

CORFIELD,    DWELLING  HOUSES. 

The  Sanitary  Construction  and  Arrangement  of  Dwelling  Houses.  By  W. 
H.  CoRFiELD,  M.A.,  M.D.  Enlarged  Edition,  with  Plans  and  Illustrations. 
i2mo.  Price  $1.25 


PUB  Lie  A  TIONS. 


13 


COULSON,  THE  BLADDER.     Sixth  Edition. 

Diseases  of  the  Bladder  and  Prostate  Gland.     By  Walter  J.  CouLSON,  F.R.c.S. 
Sixth  Edition.     Revised  and  Enlarged,  with  22  Engravings.     8vo.      Price  $6.40 

CRIPPS,  THE  RECTUM. 

Cancer  of  the   Rectum.     Its  Pathology,  Diagnosis  and  Treatment.     By.  W. 
Harrison  Cripps,  f.r.c.s.     Illustrated  by  Plates.     8vo.  Price  $2.40 

DAY  ON  CHILDREN.     Second  Edition.     Just  Ready. 

The  Diseases  of  Children.     A  Practical  and  Systematic  Treatise  for  Practi- 


tioners and  Students, 
very  much  Enlarged. 


By  Wm.  H.  Day,  m.d. 
8vo.     752  pp. 


Second  Edition.     Rev/ritten  and 
Price,  Cloth,  $5.00 ;  Sheep,  $6.00 


"  Dr.  Day  brings  to  his  task  a  large  experience,  and 
evidences  a  very  thorough  knowledge  of  the  literature, 
native  and  foreign,  pertaining  to  this  special  branch  of 
medicine.  The  book  has  been  written  with  great  care, 
and  the  author  is  a  good  writer.  The  publisher's  part 
of  the  task  has  also  been  excellently  performed." — 
Boston  Medical  and  Surgical  Journal. 


"  Believing  the  work  well  adapted  to  meet  the  wants 
of  the  Student  as  well  as  the  Practitioner,  I  will  recom- 
mend it  to  the  classes  of  Rush  Medical  College." — 
DeLeskie  Miller,  m.d.,  Chicago. 

"  On  the  whole,  we  must  confess  we  are  pleased  with 
this  book  and  can  heartily  recommend  it — a  recommen- 
dation which  it  does  not  appear  to  need,  as  it  has 
already  reached  its  second  edition." — American  Jour- 
nal of  Medical  Science. 

"DPCI  ON  HEADACHES. 

The  Nature,  Causes,  and  Treatment  of  Headaches.     Third  Edition.     Illus- 
trated.    By  Wm.  Henry  Day,  m.d.  Price  I1.25 

Summary  of  Contents. — Headache  from  Cerebral  Anaemia,  Cerebral  Hypersemia,  Sympathetic,  Congestive, 
Dyspeptic  or  Bilious  Headaches,  Headache  from  Plethora,  from  Exhaustion,  from  Change  in  Cerebral  Tissue, 
from  Affections  of  the"Periosteum,  Nervous  and  Nervo-Hypersemic  Headache,  Toxaemic,  Rheumatic,  Arthritic 
or  Gouty  Headache,  Neuralgic  Headache,  and  Headaches  of  Childhood,  Early  and  Advanced  Life. 

"  Well  worth  reading.     The  remarks  on  treatment  are  very  sensible." — Boston  Medical  and  Surg.  Journal . 

DALBY,  ON  THE  EAR. 

The  Diseases  and  Injuries  of  the  Ear.     By  W.  B.  Dalby,  m.d.,  Surgeon  and 
Lecturer  on  Aural  Surgery,  St.  George's  Hospital.     With  Illustrations.     i2mo. 

Price  $1.50 

'A  safe  and  readable  introduction  to  aural  surgery." 
Medical  Press  and  Circular. 

"  Dr.  Dalby  has  presented  us  with  a  very  readable 
little  book,  which  is  destined  to  render  rsuch  service  in 
the  saving  of  ears." — l\l.  V.  Medical  Journal. 


"  The  lectures  occupy  2z6  pages,  are  clearly  and 
consisely  written,  contain  a  number  of  good  illustrations, 
and  are  well  worth  the  careful  study  of  both  student 
and  practitioner.  To  aurists  the  work  will  be  most 
welcome  and  valuable." — Specialist. 


DILLINGBERGER,     WOMEN     AND     CHILDREN'S     DIS- 
EASES. 

A  Hand-Book  of  the  Treatment  of  the  Diseases  Peculiar  to  Women  and  Chil- 
dren.    By  Dr.  Emil  Dillingberger.     i2mo.  •  Price  $1.50 

"  It  is  a  tnagnum  in  parvo.     The  style  is  simple,  clear,  lucid,  and  free  from  theoretical  discussion.    No  one  will 
regret  the  small  outlay  for  this  volume. — Richmond  and  Louisville  Medical  Journal. 

DUNGLISON,  THE  PHYSICIAN'S  REFERENCE  BOOK. 

The  Practitioner's  Reference  Book,  containing  Therapeutical  and  Practical 
Hints,  Dietetic  Rules,  and  General  Information.  By  Richard  J.  Dunglison, 
M.D.       Third  Edition.     Svo.  Price  $3.50 

"  The  demand  for  a  second  edition  so  soon  after  the 
publication  of  the  first  volume  shows  that  this  work  is 
appreciated  by  the  profession." — Canada  Lancet. 


"  We  can  heartily  commend  this  book  as  one  that 
must  prove  very  useful  to  the  general  practitioner." — 
The  Medical  Record. 


DURKEE,  VENEREAL  DISEASES.     Sixth  Edition. 

Gonorrhoea  and  Syphilis.     By  Silas  Durkee,  m.d.     Sixth  Edition.     Revised 
and  Enlarged,  with  Portrait  and  Eight  Colored  Illustrations.     Svo.     Price  $3.50 

"We  may,  finally,  recommend  Dr.  Durkee's  book  as  eminently  practical,  well  written,  full  of  excellent  counsel, 
and  worthy  of  being  corsiltcd  by  every  member  of  the  profession.  A  late  number  of  the  London  Mrdical  Times 
atid  Gazette  also  speaks  of  the  book  in  terms  of  the  highest  approval." — Boston  Medical  and  Surgical  Journal, 


14  PRESLE V  BLAKISTON'S 

DAGUENET,  OPHTHALMOSCOPY. 

A  Manual  of  Ophthalmoscopy,  for  the  Use  of  Students.  By  Dr.  Daguenet. 
Translated  from  the  French,  by  Dr.  C.  S.  Jeaffreson,  f.r.c.S.e.  Illustrated. 
i2mo.  Price  $1.50 

"Its  portable  size,  the  condensed  nature  of  its  text,  and  the  admirably  systematic  arrangement  of  its  contents, 
render  it  extremely  useful  as  a  pocket  manual  for  Students. —  Translator' s Preface. 

DOBELL,  WINTER  COUGH  AND  CATARRH. 

On  Winter  Cough,  Catarrh,  Bronchitis,  Emphysema,  Asthma,  etc.  By 
Horace  Dobell,  m.d..  Lecturer  at  the  Royal  Hospital  for  Diseases  of  the 
Chest.     Third  Edition.    With  Colored  Plates.     8vo.  Price  {^3. 50 

BY    SAME   AUTHOR. 

ON  LOSS  OF  WEIGHT.     Revised  Edition. 

Blood  Spitting  and  Lung  Disease.  Colored  Frontispiece  of  Lung.  Tabular 
Map,  etc.     Second  Edition  Enlarged.     8vo.  Price  $4.00 

DOMVILLE,  ON  NURSING. 

A  Manual  for  Hospital  Nurses  and  others  engaged  in  attending  to  the  sick, 
4th  Edition.     With  Recipes  for  Sick  Room  Cookery,  etc.  Price  .75 

DRUITT'S  MODERN  SURGERY.     Eleventh  Edition. 

The  Surgeon's  Vade  Mecum;  a  Manual  of  Modern  Surgery.  By  Robert 
Druitt,  f.r.c.s.  Eleventh  Enlarged  Edition,  with  369  Illustrations.  864  pp. 
1878.  Price  §5.00 

This  is  a  most  complete,  accurate,  and  trustworthy  Hand,  or  Text-Book  of  Sur- 
gery. Unrivaled  as  a  book  for  the  Student.  Fully  illustrated,  and  brought  up  to 
the  present  state  of  the  science.     In  use  in  many  Medical  Colleges. 

DULLES,  ACCIDENTS. 

What  to  do  First,  in  Accidents  and  Poisoning.  By  C.  W.  Dulles,  m.d.  Il- 
lustrated.    i6mo.  Price  .50 


"  Its  usefulness  entitles  it  to  a  wide  and  permanent 
circulation." — Boston  Gazette. 

"  A  complete  guide  for  sudden  emergencies. — Phila- 
delphia  Ledger. 


"  So  plain  and  sensible  that  it  ought  to  be  introduced 
into  every  female  seminary. — Evemtig  Chronicle, 
Pittsburgh. 


EDWARDS,  BRIGHT'S  DISEASE.     New  Edition. 

How  a  Person  Affected  with  Bright's  Disease  Ought  to  Live.  By  Jos.  F.  Ed- 
wards, M.D.     Second  Edition.     i2mo.  Price  .75 

BY  same  author. 

DYSPEPSIA.    Just  Ready. 

How  to  Avoid  It.     i2mo.  .75 

Contents. — Chap.  i. — Food.    11.  Digestion,    iii.  How  to  Cook  Food.    iv.  How  and  What  We  Ought  to  Eat. 

CONSTIPATION.     New  Edition. 

Plainly  Treated  and  Relieved  Without  the  Use  of  Drugs.  Second  Edition. 
i2mo.  Price  .75 

MALARIA. 

Malaria  :  What  It  Means ;  How  to  Escape  It ;  Its  Symptoms ;  When  and 
Where  to  Look  for  It.     i2mo.  Price  .75 

VACCINATION  AND  SMALL-POX. 

Showing  the  Reasons  in  favor  of  Vaccination,  and  the  Fallacy  of  the  Argu- 
ments Advanced  against  it,  with  Hints  on  the  Management  and  Care  of  SmaH- 
Pox  patients.     i6mo.  Price  .50 

These  are  invaluable  little  treatises  upon  subjects  that  enter  painfully  into  the 
life  experiences  of  a  large  majority  of  the  human  family.  Dr.  Edwards  shows  not 
only  how  they  may  be  avoided,  but  in  plain  and  simple  language  he  tells  those 
already  afflicted  with  them  how  they  may  find  relief. 


PUBLICA  TIONS. 


15 


EKIN,  WATER  ANALYSIS. 

Potable  Water.  How  to  Form  a  Judgment  on  the  Suitableness  of  Water  for 
Drinking  Purposes.     By  Charles  Ekin.     Second  Edition.     i2mo.        Price  .75 

ELLIS,  DISEASES  OF  CHILDREN. 

A  Practical  Manual  of  the  Diseases  of  Children,  with  a  Formulary.  By  Ed- 
ward Ellis,  m.d.  Late  Physician  to  the  Victoria  Hospital  for  Children, 
London.     Fourth  Edition  Enlarged.     Now  Ready.  Price  ^3.50 

BY   SAME  AUTHOR. 

WHAT  EVERY  MOTHER  SHOULD  KNOW. 

l2mo.  Price  .75 

"  It  is  only  too  true  that  our  children  have  to  dodge  through  the  early  part  of  life  as  through  a  labyrinth.  We 
must  be  thankful  to  meet  with  such  a  sensible  guide  for  them  as  Dr.  Ellis." — Pall  Mall  Gazette. 

FENNER,  ON  VISION. 

Vision ;  Its  Optical  Defects,  the  Adaptation  of  Spectacles,  Defects  of  Accommo- 
dation, etc.  By  C.  S.  Fenner,  m.d.  With  Test  Types  and  74  Illustrations. 
8vo.  Price  $3.50 

FENWICK,  THE  PRACTICE  OF  MEDICINE. 

Outlines  of  the  Practice  of  Medicine.  With  Appropriate  Formulae  and  Illus- 
trations.   By  Samuel  Fenwick,  m.d.,  Physician  to  the  London  Hospital.    i2mo. 

Price  ^1.25 

"This  little  work  displays  a  sound  judgment  in  the  arrangement  of  its  subject  matter,  and  an  intimate  acquaint- 
ance with  the  practice  of  medicine  possessed  by  but  few  writers,  and  should  have  been  elaborated  into  a  more 
comprehensive  work.     Of  all  the  hand-books  we  have  seen,  this  is  certainly  one  of  the  best." — Medical  Herald. 

"  It  is  an  eminently  practieal  little  treatise,  pervaded  with  much  common  sense,  and  will  doubtless  be  found 
useful,  particularly  by  advanced  students." — Boston  Medical  and  Surgical  yournal. 

BY  SAME  AUTHOR. 

ON  THE  STOMACH. 

The  Morbid  State  of  the  Stomach  and  Duodenum,  and  Their  Relations  to 
Diseases  of  Other  Organs.     With  10  Plates.     8vo.  Price  $4.25 

Atrophy  of  the  Stomach  and  Its  Effect  on  the  Nervous  Affections  of  the  Digest- 
ive Organs.     8vo.  Price  %'i.io 


FOTHERGILL,  ON  THE  HEART.     Second  Edition. 

The  Heart  and  Its  Diseases.  With  Their  Treatment.  Including  the  Gouty 
Heart.  By  J.  Milner  Fothergill,  m.d.,  Associate  Fellow  of  the  College  of 
Physicians  of  Philadelphia.      Second  Edition,    Entirely   Re-written.     Octavo. 

Price  #3.50 


"  It  is  the  best,  as  well  as  the  most  recent  work  on 
the  subject  in  the  English  language." — Medical  Press 
and  Circular. 

"  The  most  interesting  chapter  is  undoubtedly  that 
on  the  gouty  heart,  a  subject  which  Dr.  Fothergill  has 
specially  studied,  and  on  which  he  entertains  views 
such  as  are  likely,  we  think,  to  be  generally  accepted 
by  clinical  ^bysicians,  although  they  have  not  before 
been  stated,  so  far  as  we  are  aware,  with  the  same 
breadth  of  view  and  extended  illustration." — Britith 
Medical  yournal. 


"  To  many  an  earnest  student  it  will  prove  a  Kght  in 
darkness ;  to  many  a  practitioner  cast  down  with  a 
sense  of  his  powerlessness  to  cope  with  the  rout  and 
demoralization  of  Nature's  forces,  a  present  help  in 
time  of  trouble." — Philadelphia  Medical  Times. 

"  The  work  throughout  is  a  masterpiece  of  graphie, 
lucid  writing,  full  of  good,  sound  teaching,  which  will 
be  appreciated  alike  by  the  practitioner  and  the  stu- 
dent.— Students'  yournal. 


FULTON,  ON  PHYSIOLOGY. 

A   Text-Book  of  Physiology.    By  J.  Fulton,  m.d.,  Professor  at   Trinity 
Medical  College,   Toronto.     Second  Edition,  Illustrated  and  Revised.    Svo. 

Price  $4.00 


1 6  PRESLEY  BLAKISTON'S 

FLOWER,  DIAGRAMS  OF  THE  NERVES. 

Diagrams  of  the  Nerves  of  the  Human  Body.  Exhibiting  their  Origin, 
Divisions,  and  Connections,  with  their  Distribution  to  the  various  Regions  of  the 
Cutaneous  Surface,  and  to  all  the  Muscles.  By  William  H.  Flower,  f.r.c.s., 
F.R.S.,  Hunterian  Professor  of  Comparative  Anatomy,  and  Conservator  of  the 
Museum  of  the  Royal  College  of  Surgeons.  Third  Edition,  thoroughly  revised. 
With  six  Large  Folio  Maps,  or  Diagrams.     Royal  Quarto.  Price  $3.50 

"Admirably  arranged,  and  will  be  of  incalculable  aid  to  the  student  of  anatomy.  Each  of  the  large  and 
beautiful  plates  is  accompanied  with  explanatory  text." — N.  Y.  Medical  Record. 

"  The  nerves  and  ganglia  are  clearly  represented.  The  impressions  are  well  made,  and  no  doubt  the  diagrams 
will  prove  useful." — Medical  and  Surgical  Reporter . 

FLAGG,  PLASTIC  FILLING. 

Plastics  and  Plastic  Filling;  As  Pertaining  to  the  Filling  of  all  Cavities  of  De- 
cay in  Teeth  below  Medium  in  Structure,  and  to  Difficult  and  Inaccessible 
Cavities  in  Teeth  of  all  Grades  of  Structure.  With  some  beautifully  executed 
Illustrations.  By  J.  Foster  Flagg,  d.d.s..  Professor  of  Dental  Pathology  and 
Therapeutics  in  Philadelphia  Dental  College.     Octavo.  Price  $3.00 

Contents. — Introductory.  Article  i.  Plastic  Filling.  2.  Amalgam.  3.  Amalgam  continued.  4.  Amalgam 
continued.  5.  Attributes  of  Metals  used  for  Amalgam  Alloys.  6.  The  Making  of  Amalgam  Alloys.  7.  Tests 
for  Amalgam.  8.  Preparation  of  Cavities.  9.  The  Making  of  Amalgam.  10.  Instrument  for  the  Insertion  of 
Amalgam  Fillings.  11.  The  Insertion  of  Amalgam  Fillings.  12.  General  Considerations  Pertaining  to  Amalgam. 
13.  Gutta-percha.  14.  Oxy-chloride  of  Zinc.  15.  Oxy-sulphate  of  Zinc.  16.  Zinc  Phosphate.  17.  Temporary 
Stopping.     18.  Technicalities.     Conclusion. 

FOSTER,  CLINICAL  MEDICINE. 

Lectures  and  Essays  on  Clinical  Medicine.  By  Balthazar  Foster,  m.d. 
Illustrated.     8vo.  Price  S3.00 


"No  one  can  peruse  the  thoughtful  comments  of  our 
author  upon  every  subject  he  considers,  without  feeling 
himself  a  wiser  man  for  his  pains."— A^.  Y.  Medical 
Journal. 


"It  is  the  record  of  honest  work,  such  as  Dr.  Foster 
may  be  proud  of;  we  can  recommend  it  to  the  profession; 
it  may  be  read  with  profit  and  advantage  by  both  prac- 
titioner and  %\.\<iA^Vi.t.— Edinburgh  Medical  yournal. 


FOX,  ATLAS  OF  SKIN  DISEASES. 

Complete  in  Eighteen  Parts,  each  containing  Four  Chromo-Lithographic  Plates, 
with  Descriptive  Text  and  Notes  upon  Treatment.  In  all  72  large  colored  Plates. 
By  Tilbury  Fox,  m.d.,  f.r.c.p.,  Physician  to  the  Department  for  Skin  Diseases 
in  University  College  Hospital.     Folio  Size. 

Price  ^i.oo  each,  or  complete,  bound  in  cloth,  $20.00 

No  Atlas  of  Skin  Diseases  has  been  issued  in  this  country  for  many  years,  and  no 
complete  work  of  the  kind  is  now  procurable  by  the  Profession.  This  one,  brought 
out  under  the  editorial  supervision  and  care  of  Dr.  Tilbury  Fox  (the  most  distin- 
guished writer  on  Cutaneous  Medicine  now  in  the  English  language),  is  partly  based 
upon  the  classical  work  of  Willan  and  Bateman  (now  entirely  out  of  print),  but  com- 
pletely rem.odeled,  so  as  to  represent  fully  the  Dermatology  of  the  present  day. 

"  Preference  v/ill  be  given  to  this  work  over  Hebra ;  not  simply,  however,  because  it  is  a  home  production,  but 
by  reason  of  the  manner  of  its  execution,  the  excellent  delineation  of  disease,  and  the  natural  coloring  of  the  plates. 
The'  letter-press  is  entirely  new.     In  the  accuracy  of  the  latter  the  subscriber  may  have  the  fullest  confi- 
dericej  since  it  is  from  the  pen  of  Dr.  Tilbury  'Eox."— British  and  Foreign  Medico-Chirurgical  Review. 

FRANKLAND,  WATER  ANALYSIS. 

Water  Analysis,  For  Sanitary  Purposes,  with  Hints  for  the  Interpretation  of 
Results.     By  E.  Frankland,  m.d.,  f.r.S.     Illustrated.     l2mo.  Price  $1.00 

"The  author's  world-wide  reputation  will  commend 
this  manual  to  all  sanitarians,  and  they  will  not  be  dis- 
appointed in  finding  all  the  essentials  of  the  important 
subject  of  which  it  treats."— TVi^  Sanitarian. 


"The  work  is  one  which  physicians  practicing  ia 
the  country  and  in  villages  and  towns  remote  from 
medical  centres  cannot  aflford  to  be  without." — Medical 
and  Surgical  Reporter. 


BY  SAME  AUTHOR. 

CHEMISTRY. 

How  to  Teach  Chemistry;  being  Six  Lectures  to  Science  Teachers.^  Edited 
by  G.  George  Ghalo^er,  f.c.s.    Illustrated,     izmo.  Price  1^1.25 


PUB  Lie  A  TIONS. 


17 


FOX,  WATER,  AIR  AND  FOOD. 

Sanitary  Examinations  of  Water,  Air  and  Food. 
M.D.     94  Engravings.     8vo. 


By 


Cornelius  B.  Fox, 
Price  %A..oo 


gajLLAbin,  diseases  of  women 

The  Student's  Guide  to  the  Diseases  of  Women. 
M.D.,  F.R.c.P.     Illustrated  with  63  Engravings 


By  A.  Lewis  Gallabin,  m.a., 
i2mo.  Price  $1.25 


"Among  all  the  various  works  on  diseases  of  women 
with  which  we  are  acquainted,  there  is  none  which  so 
nearly  approaches  the  perfection  of  what  a  student's 
text-book  should  be  .  .  .  The  work  is  well  illustrated." 
— Students'  Journal. 

"  Though  the  book  is  a  small  one  and  the  subject  ex- 
tensive, yet  so  admirable  is  the  style  of  the  writer,  and 
so  careful  his  selection  of  words,  that  each  disease  is 
thoroughly  treated  of" — Philadelphia  Medical  Times. 


"  Its  style  is  clear,  elegant,  and  concise:  It  contains 
a  great  amount  of  information  ;  indeed,  we  do  not  think 
the  student  or  practitioner  will  find  any  book  which 
will  convey  to  him  in  so  small  a  compass  so  much  accu- 
rate knowledge  about  the  pathology  and  diagnosis  of 
the  diseases  peculiar  to  women." — Medical  Times  and 
Gazette. 


GROSS,  BIOGRAPHY  OF  JOHN  HUNTER. 

John  Hunter  and  His  Pupils.  By  S.  D.  Gross,  m.d..  Professor  of  Surgery  in 
Jefferson  Medical  College,  Philadelphia.  With  a  beautifully  executed  full  length 
Portrait  of  the  Author  in  his  Study.  A  Handsome  Octavo  volume.  Bound  in 
Beveled  Cloth.  Price  $1.50 

"  It  is  refreshing  to  read  the  story  of  a  life  so  fully  devoted  to  science,  and  the  reader  will  readily  appreciate 
Professor  Gross's  enthusiasm  for  his  subject,  which  led  him  to  extend  what  was  originally  intended  for  an  essay  to 
its  present  size. 

'•  The  phototype  of  Sharp's  well-known  engraving  of  Sir  Joshua  Reynold's  portrait  is  an  excellent  reproduction, 
and  forms  a  fitting  and  handsome  frontispiece. 

"  The  volume  will  prove  an  ornament  to  the  study  table,  where  it  will  be  a  constant  incentive  to  whatever  is 
best  and  noblest  in  a  noble  profession." — Baston  Med.  and  Surgical  Journal. 

BY   SAME  AUTHOR. 

AMERICAN  MEDICAL  MEN. 

American  Medical  Biography  of  the  Nineteenth  Century,  vi'ith  portrait  of  Dr. 
Benjamin  Rush.     Large  8vo. 

GANT,  A  SYSTEM  OF  SURGERY.     Enlarged  Edition. 

The  Science  and  Practice  of  Surgery,  including  Special  Chapters  by  different 
Authors.  By  Frederick  James  Gant,  f.r.c.s..  Senior  Surgeon  to  the  Royal 
Free  Hospital.  Second  Edition,  rewritten  and  much  enlarged  throughout. 
Illustrated  by  969  wood  engravings.     In  two  Octavo  volumes. 

Price,  Cloth  $11.00;  Leather  $13.00 

"  This  new  and  magnificent  work  on  surgery  sup- 
plies all  that  can  be  required,  whether  for  the  most  com- 
plete study  or  for  constant  reference  in  practice." — 
London  Medical  Press  and  Circular. 

"  The  reader  has  the  advantage  of  mature  experience 
in  treating  of  special  subjects,  that  are  either  omitted 
or  very  lightly  referred  to  in  ordinary  works  on  sur- 
gery."— London  Lancet. 


"  After  the  most  patient  analysis  our  limited  time 
has  permitted,  we  feel  compelled  to  say  that  this  book 
is  a  valuable  and  comprehensive  addition  to  the  surgical 
literature  of  the  profession  and  a  monument  to  the  care- 
ful, conscientious  and  painstaking  industry  of  the 
author," — Cincinnati  Lancet  and  Observer. 


BY   SAME   AUTHOR. 

ON  THE  BLADDER  AND  PROSTATE. 

Diseases  of  the  Bladder  and  Prostate  Gland  and  Urethra,  including  a  Practical 
View  of  Urinary  Diseases,  Deposits  and  Calculi.  Fourth  Edition,  Revised  and 
Enlarged,  with  New  Illustrations.     i2mo.  Price  $3.00 

GIBBES,  STUDENT'S  PATHOLOGY. 

Practical  rfistology  and  Pathology.  By  Heneage  Gibbes,  m.b.  i2mo. 
Cloth.  Price  $1.00 

Chap.  i.  Introduction.  2.  On  Preparing  Tissues  for  Examination.  3.  On  Cutting  Sections.  4.  On  Staining. 
S-  On  Double  Staining.  6.  On  Mounting.  7.  Method  of  Obtaining  Animal  Tissues,  etc.  Practical  Histology, 
Pathoiogy,  Memoranda  and  Formulffi. 

"  This  excellent  little  work  is  admirably  adapted  to  fulfill  the  purpose  for  which  it  has  been  written.  It  is 
short,  clear,  and  eminently  practical.  The  author  is  evidently  an  accomplished  histologist,  and  his  book  conveys 
the  impression  that  it  is  based  upon  his  own  personal  experience." — The  London  Medical  Record. 


i8  PRESLEY  BLAKISTON'S 

GODLEE'S  ATLAS  OF  HUMAN  ANATOMY. 

Illustrating  most  of  the  Ordinary  Dissections  and  many  not  usually  practiced 
by  the  Student.  Accompanied  by  References  and  an  Explanatory  Text.  Com- 
plete. Folio  Size.  48  Colored  Plates.  By  Rickman  John  Godlee,  m.d., 
F.R.c.S.  Forming  a  large  Folio  Volume,  with  References,  and  an  Octavo 
Volume  of  Letter-press. 

Price  of  the  two  Volumes,  Atlas  and  Letter-press,  Cloth,  $20.00 

"  It  is  likely  to  prove  as  useful  to  the  physician  and  I  "  The  explanatory  text  is  concise,  well  written,  and 
surgeon  as  to  the  anatomist." — Medical  Times  and  contains  many  valuable  suggestions  for  the  surgeon." 
Gazette.  \    — London  Lancet. 

GOWERS,  SPINAL  CORD. 

Diagnosis  of  Diseases  of  the  Spinal  Cord.  With  Colored  Plates  and  Engrav- 
ings. A  Second  Edition,  Revised  and  Enlarged.  By  William  R.  Cowers, 
M.D.,  Assistant  Professor  Clinical  Medicine,  University  College,  London,  8vo. 
Second  Edition.  Price  $1.50 

BY   same  author. 

OPHTHALMOSCOPY. 

A  Manual  and  Atlas  of  Medical  Ophthalmoscopy.  With  16  Colored  Auto" 
type  and  Lithographic  Plates  and  26  Wood  Cuts,  comprising  112  Original  Illus- 
trations of  the  Changes  in  the  Eye  in  Diseases  of  the  Brain,  Kidneys,  etc.   8vq. 

Price  $6.00 
EPILEPSY  AND  ITS  TREATMENT. 

Epilepsy  and  other  Chronic  Convulsive  Diseases  :  Their  Causes,  Symptoms, 
and  Treatment.     Octavo,     ynst  Ready.  Price,  Cloth,  $4.00 

NERVOUS  DISEASES. 

A  Manual  of  Diseases  of  the  Nervous  System,  for  Practitioners  and  Students. 

In  Press. 

"  Dr.  Gowers,  while  profoundly  conversant  with  the  literature  of  his  subject,  has  not  allowed  himself  to  be 
influenced  to  an  undue  extent  by  the  writings  of  others,  but  while  fairly  stating  their  views,  where  this  is  neces- 
sary, he  at  the  same  time  brings  to  bear  upon  them  the  experience  derived  from  his  own  extensive  observations, 
and  when,  consequently,  they  receive  confirmation  or  not  at  his  hands,  they  are  all  the  more  valuable  as  being  the 
outcome  of  the  most  searching  and  unbiased  criticism.  It  would  be  impossible,  within  the  limits  of  a  short  re- 
view, to  convey  an  adequate  idea  of  the  extent  of  Dr.  Gowers'  work." — Edinburgh  Medical  jfournal. 

GREENHOW,  BRONCHITIS. 

On  Chronic  Bronchitis,  especially  as  connected  with  Gout,  Emphysema,  and 
Diseases  of  the  Heart.     By  E.  Headlam  Greenhow,  m.d.  i2mo.      Price  $1.50 

BY    SAME   AUTHOR. 

ADDISON'S  DISEASE. 

Being  the  Croonian  Lectures,  delivered  before  the  Royal  College  of  Physi- 
cians, London.     Revised  and  Illustrated  by  Plates  and  Reports  of  Cases.     8vo. 

Price  $3.00 

"The  book  forms  a  most  interesting  and  valuable  monograph,  comprehensive  and  exhaustive." — British 
Medical  Journal. 

GLISAN,  TEXT-BOOK  OF  MODERN  MIDWIFERY. 

A  Text-Book  of  Modern  Midwifery.  By  Rodney  Glisan,  m.d.,  Emeritus 
Professor  of  Midwifery  and  Diseases  of  Women  and  Children  in  the  Medical 
Department  of  Willamette  University,  Portland,  Oregon,  and  Late  President 
of  the  Oregon  State  Medical  Society.  With  129  Illustratiolis.  One  Volume, 
octavo,  624  pp.  Price,  in  Cloth  $4.00 ;  in  Leather  I5.00 

GILL,  ON  INDIGESTION.     Third  Edition. 

Indigestion  ;  What  It  Is ;  What  It  Leads  To  ;  and  a  New  Method  of  Treating 
It.    By  John  Beadnell  Gill,  m.d.    Second  Edition.     i2mo. 


PUBLICA  TIONS.  19 


HABERSHON,  ON  THE  STOMACH. 

On  Diseases  of  the  Stomach — The  Varieties  of  Dyspepsia — Their  Diagnosis 
and  Treatment.  By  S.  O.  Habershon,  m.d.,  f.r.c.p.,  Senior  Physician  to,  and 
Late  Lecturer  on,  the  Principles  and  Practice  of  Medicine  at  Guy's  Hospital. 
Third  Edition,  Revised.     Crown  8vo.  Price  ^1.25 

"As  an  expression  of  the  results  of  long  personal  experience  in  both  hospital  and  private  practice,  conveyed 
in  agreeable  though  not  always  perspicuous  diction,  this  contribution  of  Dr.  Habershon's  has  special  value  of  its 
own,  and  is  so  far  entitled  to  the  favorable  consideration  of  the  practitioner,  as  is  already  testified  by  a  demand 
for  a  third  edition." — American  yournal  of  Medical  Sciences. 

HALE,  ON  CHILDREN. 

The  Management  of  Children  in  Health  and  Disease.  A  Book  for  Mothers. 
By  Mrs.  Amie  M.  Hale,  m.d.  Abounding  in  valuable  information  and  com- 
mon sense  advice.     New  Enlarged  Edition.     i2mo.  Price  .75 

"  We  shall  use  our  influence  in  the  introduction  of  this  work  to  families  under  our  care,  and  we  urge  the  pro- 
fession generally  to  follow  our  example." — Buffalo  Medical  and  Surgical  Journal. 

HUGHES,  QUIZ-BOOK  OF  PRACTICE. 

A  Compend  of  the  Practice  of  Medicine,  as  used  in  the  Quiz-Rooms  and  Ex- 
aminations in  the  principal  Medical  Colleges.  By  Daniel  E.  Hughes,  m.d., 
Demonstrator  of  Clinical  Medicine  at  Jefferson  Medical  College,  Philadelphia. 
In  two  parts.  Quiz-CompendSeries  Nos.  2  and  3.    i2mo.  Cloth.    Price,  each,  ^1.25 

HARDWICKE,  MEDICAL  EDUCATION. 

Medical  Education  and  Practice  in  All  Parts  of  the  World.  Containing 
Regulations  for  Graduation  at  the  Various  Universities  throughout  the  World. 
By  Herbert  Junius  Hardwicke,  m.d.,  m.r.c.p.     8vo.;  Price  ^3.00 

"  Dr.  Hardwicke's  book  will  prove  a  valuable  source  of  information  to  those  who  may  desire  to  know  the 
conditions  upon  which  medical  practice  is  or  may  be  pursued  in  any  or  every  country  of  the  world,  even  to  the 
lemotest  corners  of  the  earth.  The  work  has  been  compiled  with  great  care,  and  must  have  required  a  vast 
amount  of  labor  and  perseverance  on  the  part  of  its  author." — Dublin  Medical  yournal. 

HARLEY,  ON  THE  LIVER.     Illustrated. 

On  Diseases  of  the  Liver,  with  or  without  Jaundice.  Diagnosis  and  Treat- 
ment, By  George  Harley,  m.d.  Author  of  the  Urine  and  Its  Derangements. 
With  Colored  Plates  and  Numerous  Illustrations.     Royal  Octavo. 

In  Rapid  Preparation. 
HAYDEN,  ON  THE  HEART. 

The  Diseases  of  the  Heart  and  Aorta.  By  Thomas  Hayden,  m.d.  With  81 
Illustrations.     2  vols.     1232  pp.     8vo.  Price  $6.00 

"The  author  evidently  has  had  a  very  wide  and  well  used  experience  in  that  of  which  he  writes  ;  is  well  versed 
in  modern  physiology  and  pathology,  and  holds  a  fluent  pen,  consequently  the  book  is  an  excellent  one,  and  as 
the  teachings  of  the  text  are  abundantly  illustrated  by  the  reports  of  one  hundred  and  fifty  cases.  Dr.  Hayden's 
efifort  will  probably  attain  the  popularity  it  deserves." — i'hiladelphia  Medical  Titnes. 

"There  is  not  an  unnecessary  page  in  Dr.  Hayden's  work." — N.  Y.  Medical  Record. 

HOLDEN,  HUMAN  OSTEOLOGY.     Sixth  Edition. 

Comprising  a  Description  of  tiie  15ones,  with  Colored  Delineations  of  the  At- 
tachments of  the  Muscles.  The  General  and  Microscopical  Structure  of  ]5one 
and  its  Development.  By  the  Author  and  A.  Doran,  f.r.c.s.,  with  Lithographic 
Plates,  etc.  By  Luther  Holden,  f.r.c.s.  Numerous  Illustrations.  Sixth 
Edition,  carefully  Revised.  Price  $6.00 

BY   same   AUTHOR. 

ANATOMY. 

Manual  of  Dissections  of  the  Human  Body.  Fourth  London  Edition,  Witli 
170  Illustrations.  Price  ^z,.t,o 

LANDMARKS. 

Landmarks,  Medical  and  Surgical.  Third  London  Edition.  Revised  and 
Enlarged.  Price  ;?i. 00 

"  Mr.  Holden  is  the  happy  possessor  of  the  faculty  of  writing  interesting  works  on  Anatomy.  A  part  of  the 
charm  consists  in  the  frequent  references  to  practical  points,  and  in  the  explanation  of  the  advantages  ait'  objects 
of  details  of  structures." — Boston  Medical  and  Surgical  yournal. 


20  PRESLE  V  BLAKISTON 'S 

HEATH'S  OPERATIVE  SURGERY. 

A  Course  of  Operative  Surgery,  consisting  of  a  Series  of  Plates,  each  plate 
containing  Numerous  Figures,  Drawn  from  Nature  by  the  Celebrated  Anatomi- 
cal Artist,  M.  Leveille,  of  Paris,  Engraved  on  Steel  and  Colored  by  Hand, 
under  his  immediate  superintendence,  with  Descriptive  Text  of  Each  Operation. 
By  Christopher  Heath,  f.r.c.s..  Surgeon  to  University  College  Hospital,  and 
Holme  Professor  of  Clinical  Surgery  in  University  College,  London.  One  Large 
Quarto  Volume.  Price  §14.00 

The  author  has  embodied  in  this  work  the  experience  gained  by  him  during 
twenty  years  of  surgical  teaching.  It  comprises  all  the  operations  that  are  required 
in  ordinary  surgical  practice.  He  has  selected  for  illustration  and  description  those 
methods  which  appear  to  give  the  best  results  in  practice,  referring  to  the  errors 
likely  to  occur  and  the  best  methods  of  avoiding  them. 

BY   SAME   author. 

THE   STUDENT'S  GUIDE  TO  SURGICAL   DIAGNOSIS. 

i2mo.  Price  gi. 25 

"  Mr.  Heath  is  so  well  known,  both  as  a  practical  surgeon,  teacher  and  writer,  that  anything  from  his  pen  re- 
quires no  introduction  from  the  hands  of  reviewers,  and  scarcely  any  notice  but  the  announcement  of  the  fact  that 
he  has  written  a  book." — Medical  Record. 

A  MANUAL  OF   MINOR    SURGERY   AND  BANDAGING. 

Sixth    Edition,    Revised    and   Enlarged.      With    115    Illustrations.       i2mo. 

Price  $2.00 

"  This  excellent  work  should  not  be  termed  a  '  Minor '  Surgery,  but  it  really  consists  of  the  sum  and  substance 
ef  Practical  surgery.    We  would  not  exchange  it  for  any  book  in  our  possession." — Southern  Clinic. 

HEATH'S  PRACTICAL  ANATOMY.     Fifth  London  Edition. 

Practical  Anatomy.  A  Manual  of  Dissections.  Fifth  London  Edition.  24 
Colored  Plates,  and  nearly  300  other  Illustrations.     Just  Ready.  Price  $5.00 

INJURIES  AND  DISEASES  OF  THE  JAWS. 

The  Jacksonian  Prize  Essay  of  the  Royal  College  of  Surgeons  of  England, 
1867.     Second  Edition,  Revised,  with   over   150  Illustrations.     Octavo. 

Price  $4-25 
HOOD,  ON  GOUT  AND  RHEUMATISM. 

A  Treatise  on  Gout,  Rheumatism,  and  the  Alhed  Affections.  Their  Treat- 
ment, Complications,  and  Prevention.  By  Peter  Hood,  m.d.  Second  Edi- 
tion, Revised  and  Enlarged.     With  some  Considerations  on  Longevity.  Octavo. 

Price  $3.50 

"  The  Observations  on  Treatment  are  specially  to  be  comme.nA&A."— London  Lancet. 

HOLDEN,  THE  SPHYGMOGRAPH. 

The  Sphygmograph.  Its  Physiological  and  Pathological  Indications.  By 
Edgar  Holden,  m.d.  Illustrated  by  Three  Hundred  Engravings  on  Wood. 
8vo.  P"^^  ^2-°° 

HOLMES,  THE  LARYNGOSCOPE. 

A  Guide  to  the  Use  of  the  Laryngoscope  in  General  Practice.  By  Gordon 
Holmes,  m.d.,  Physician  to  the  Throat  and  Ear  Infirmary.     i2mo.     Pnce  $1.00 

BY  same  author. 

VOCAL  PHYSIOLOGY.  ,      ^  ,  .     . 

Vocal  Physiology  and  Hygiene.  With  reference  to  the  Cultivation  ^and 
Preservation  of  the  Voice.     Illustrated.     i2mo.  Pnce  $2.00 

HOFF,  ON  HiEMATURIA. 

Hsematuria  as  a  Symptom  of  the  Diseases  of  the  Genito-Urmary  Organs,  by 
O,  HoFF,  M.D.     Illustrated.     i2mo.  P"^*^  -75 


PUBLICATIONS.  21 

HUNTER,  MECHANICAL  DENTISTRY. 

A  Practical  Treatise  on  the  Construction  of  the  Various  kinds  of  Artificial 
Dentures,  with  Formulae,  Receipts,  etc.  By  Charles  Hunter,  d.d.s.  100 
Illustrations.     i2mo.  Price  $2,25 

"  It  is  the  outcome  ofhis  own  experience  of  some  twenty  years  as  aMechanical  Dentist,  and  contains,  moreover, 
much  derived  from  practical  knowledge  of  other  dentists.  The  value  of  the  book  is  also  much  added  to  by  illus- 
trations. It  will  be  very  useful  to  the  Dental  Student,  and  to  all  Mechanical  Dentists." — London  Medical  Times 
And  Gazette. 

HUTCHINSON'S    ILLUSTRATIONS    OF    CLINICAL   SUR- 
GERY.    First  Volume  Complete. 

Consisting  of  Plates,  Photographs,  Woodcuts,  Diagrams,  etc.  Illustrating 
Surgical  Diseases,  Symptoms,  and  Accidents;  also  Operations  and  other 
Methods  of  Treatment.  With  Descriptive  Letter-press.  By  Jonathan  Hutch- 
inson, F.R.C.S.,  Senior  Surgeon  to  the  London  Hospital,  Surgeon  to  the  Moor- 
fields  Ophthalmic  Hospital,  and  to  the  Hospital  for  Diseases  of  the  Skin,  Black- 
friars.  In  Quarterly  Fasciculi.  ■  Imperial  4to.  Volume  i.  (Ten  Fasciculi)  bound 
complete  in  itself.  Price  $25.00.  Parts  Eleven,  Twelve,  Thirteen,  and  Fourteen 
of  Volume  2,  Now  Ready.  Each  I2.50 

HEWITT,  DISEASES  OF  WOMEN.     Third  Edition. 

The  Diagnosis,  Pathology,  and  Treatment  of  Diseases  of  Women,  Including 
the  Diagnosis  of  Pregnancy.  Founded  on  a  Course  of  Lectures  Delivered  at  St. 
Mary's  Hospital  Medical  School.  By  Graily  Hewitt,  m.d.,  Lond.,  m.r.c.p.. 
Physician  to  the  British  Lying-in  Hospital ;  Lecturer  on  Midwifery  and  Diseases 
of  Women  and  Children  at  St.  Mary's  Hospital  Medical  School;  Honorary 
Secretary  to  the  Obstetrical  Society  of  London,  etc.  The  Third  Edition.  Re- 
vised and  Enlarged,  with  New  Illustrations.     Octavo. 

Price,  Cloth  $4.00;  Leather  ^5.00 


"  Readers  of  the  former  editions  will  not  require  to 
be  told  that  the  additions  now  made  are  of  the  highest 
possible  e.xcellence."— Zi'wz^.r  and  Gazette. 

"  It  is  one  of  the  most  useful,  practical,  and  compre- 
hensive works  upon  the  subject  in  the  English  language, 
a  true  guide  to  the  student,  and  an  invaluable  means  of 
reference  for  the  teacher."— iV.  Y.  Medical  Record. 


"  The  excellent  work  of  Dr.  Hewitt  presents — in  a 
form  well  adapted  to  conduct  the  student  to  a  knowledge 
of  the  Diseases  of  Women,  and  to  assist  the  young 
practitioner  in  his  study  of  these  diseases  at  the  bedside 
of  the  patient — a  very  full  and  clear  exposition  of  the 
views  entertained  by  the  most  authoritative  teachers  as 
to  their  pathological  treatment  and  their  correct  Diag- 
nosis."—ylw^r.  Med.  yournai. 

HAY,  SARCOMATOUS  TUMOR. 

History  of  a  Case  of  Recurring  Sarcomatous  Tumor  of  the  Orbit  in  a  Child. 
By  Thomas  Hay,  m.d.     Illustrated.     Paper.  Price  .50 

HEWSON,  EARTH  IN  SURGERY. 

Earth  as  a  Topical  Application  in  Surgery,  Being  a  Full  Exposition  of  its  Use 
in  Cases  Requiring  Topical  Applications.  By  Addinell  Hewson,  m.d.  Illus- 
trated.   8vo.  Price  $2.50 

HODGE,  ON  ABORTION. 

On  Foeticide  or  Criminal  Abortion.     By  Hugh  L.  Hodge,  m.d. 

Price,  Paper,  .30;  Cloth,  .50 
HODGE,  CASE-BOOK. 

Note-Book  for  Cases  of  Ovarian  Tumors.  By  H.  Lennox  Hodge,  m.d.  With 
Diagrams.  Price,  Paper,  .50 

HIGGINS,  DISEASES  OF  THE  EYE.     Now  Ready. 

A  Hand-Book  of  Ophthalmic  Practice.  By  Charles  Higgins,  f.r.c.s. 
Ophthalmic  Assistant  Surgeon    at  Guy's   Hospital.      Second  Edition.      i6mo. 

Price  .50 

Contents. — Section  i.  Discharge  from  the  Eyes.  ii.  Intolerance  of  Light,  iii.  Iritis  and  Glaucoma,  iv. 
Diseases  of  the  Eyelids,  v.  Watering  of  the  Eye.  vi.  Acuteness  of  Vision,  Field  of  Vision,  Anomalies  of  Re- 
fraction, Astigmatism,  Accommodation,  Presbyopia,  vii.  Disturbance  of  Vision,  Use  of  the  Ophthalmoscope, 
Normal  and  Morbid  Appearances,     vni.  Injuries. 

"  We  have  rarely  seen  so  much  important  information  condensed  in  so  short  a  space." — American  Medical 
yournai. 


22  PRESLEY  BLAKISTON'S 

HARRIS,  THE  PRACTICE  OF  DENTISTRY.     Tenth  Edition. 

The  Principles  and  Practice  of  Dentistry.  Tenth  Revised  Edition.  In  great 
part  Rewritten,  Rearranged,  and  with  many  new  and  important  Illustrations. 
By  Chapin  a.  Harris,  m.d.,  d.d.s.  Edited  by  P.  H.  Austen,  m.d.,  Professor 
of  Dental  Science  and  Mechanism  in  the  Baltimore  College  of  Dental  Surgery. 
With  nearly  400  Illustrations.     Royal  Octavo.    Price,  Cloth,  $6.50 ;  Leather,  $7.50 

This  new  edition  of  Dr.  Harris'  work  has  been  thoroughly  revised  in  all  its  parts, 
more  so  than  any  previous  edition.  So  great  have  been  the  advances  in  many 
branches  of  dentistry  that  it  was  found  necessary  to  rewrite  the  articles  or  subjects, 
and  this  has  been  done  in  the  most  efficient  manner  by  Professor  Austen,  for  many 
years  an  associate  and  friend  of  Dr.  Harris,  assisted  by  Professor  Gorgas  and  Thomas 
S.  Latimer,  m.d.  The  publishers  feel  assured  that  it  will  now  be  found  the  most 
complete  text-book  for  the  student,  and  guide  for  the  practitioner  in  the  English 
language. 

BY    SAME   AUTHOR. 

MEDICAL  AND  DENTAL  DICTIONARY.     Fourth  Edition. 

A  Dictionary  of  Medical  Terminologv',  Dental  Surgery,  and  the  Collateral 
Sciences.  Fourth  Edition,  Carefully  Revised  and  Enlarged.  By  Ferdinand 
J.  S.  GoRGAS,  M.D.,  D.D.S.,  Professor  of  Dental  Surgery  in  the  Baltimore  College, 
etc.     Royal  Octavo.  Price,  Cloth,  $6.50;  Leather,  ^^7.50 

This  Dictionary,  having  passed  through  three  editions,  and  been  for  some  time 
out  of  print,  has  been  again  carefully  revised  by  F.  J.  S.  Gorgas,  m.d.,  Dr.  Harris' 
successor  as  Professor  of  Dental  Surgery  in  the  Baltimore  College  of  Dental  Surgery. 
In  his  preface  to  this  new  edition,  the  editor  says  : — 

"  The  object  of  the  reviser  has  been  to  bring  the  book  thoroughly  up  to  the  pres- 
ent requirements  of  the  profession,  the  Medical  Y>ort\on  having  been  as  carefully  re- 
vised and  added  to  as  that  devoted  more  especiall}'  to  Dental  Science,  while  a 
number  of  obsolete  terms  and  methods  have  been  omitted.  In  nearly  every  one  of 
the  seven  hundred  and  forty-three  pages  of  the  former  edition  corrections  and  addi- 
tions have  been  made,  and  many  new  processes,  terms  and  appliances  described, 
some  of  which  are  not  found  in  any  other  work  published." 

HANDY,  ANATOMY. 

Text-Book  of  Anatomy  and  Guide  to  Dissections.  For  the  Use  of  Students. 
By  W.  R.  Handy,  m.d.     312  Illustrations.  Price  S3.00 

HILLIER,  DISEASES  OF  CHILDREN. 

A  Clinical  Treatise  on  the  Diseases  of  Children.  By  Thomas  Hillier,  m.d. 
8vo.  Price  $2.00 

HUFELAND,  LONG  LIFE. 

The  Art  of  Prolonging  Life.  By  C.  W.  Hufeland.  Edited  by  Erasmus 
Wilson,  m.d.     i2mo.  Price  $i.co 

"  We  wish  all  doctors  and  all  their  intelligent  clients  would  read  it,  for  surely  its  perusai  would  be  attended 
with  pleasure  and  benefit." — American  Practitioner. 

"  It  certainly  should  be  in  the  library  of  everj-  physician."— 3/(?(/«:a/  Brief. 

HUNTER,  PORTRAIT  OF. 

Portrait  of  John  Hunter.  From  Sharp's  well-known  Engraving ;  a  copy  of 
Sir  Joshua  Reynold's  Portrait.  For  Framing.  Large  size,  9x11;  sheet  16  x  20. 
Price,  in  the  Sheet,    sent  free  by  mail,   50   cents  ;    or.  Handsomely    Framed^ 

Price  %2..oo 


PUB  Lie  A  TIONS. 


HEADLAND,  THE  ACTION  OF  MEDICINES.     Fourth  Edition. 

On  the  Action  of  Medicines  in  the  System.  By  F.  W,  Headland,  m.d. 
Fourth  American  Edition,  Revised  and  Enlarged.    8vo.  Price  $3.00 

"It  displays  in  every  page  the  evidence  of  extensive  knowledge  and  of  sound  reasoning;  it  will  be  useful  alike 
to  those  who  are  just  commencing  their  studies,  and  to  those  who  are  engaged  in  the  active  pursuits  of  pro- 
fessional Wilt."— Medical  Times. 

"  The  very  favorable  opinion  which  we  were  amongst  the  first  to  pronounce  upon  this  essay  has  been  fully 
confirmed  by  the  general  voice  of  the  profession,  and  Dr.  Headland  may  now  be  congratulated  on  having  pro- 
duced a  treatise  which  has  been  weighed  in  the  balance,  and  found  worthy  of  being  ranked  with  our  standard 
medical  works." — London  Lancet. 

JAMES,  SORE  THROAT. 

On  Sore  Throat,  Its  Nature,  Varieties  and  Treatment,  Including  its  Con- 
nection with  other  Diseases.  By  Prosser  James,  m.r.c.p.  Fourth  Edition, 
Revised  and  Enlarged.     With  Colored  Plates  and  Numerous  Wood-cuts.     i2mo- 

Price  $1.25 

"  We  can  confidently  recommend  his  therapeutic  teachings  as  well  worthy  of  the  careful  consideration  of  the 
Profession,  for  they  set  forth  the  practice  of  an  enthusiastic  worker,  whose  special  experience  has  been  large  and 
lengthened." — British  Medical  Journal. 

"  The  practitioner  who  buys  Dr.  James'  unpretending  little  book  will  provide  himself  with  a  wise  and  practical 
clinical  commentary,  and  with  a  well  arranged  digest  of  long  and  varied  experience." — Westminster  Review. 

BY  SAME  AUTHOR. 

LARYNGOSCOPY  AND  RHINOSCOPY. 

Including  the  Diagnosis  of  Diseases  of  the  Throat  and  Nose.  Third  Edition. 
With  Colored  Plates.     i8mo.  Price  $2.00. 

"  It  gives  in  a  succinct  form  the  approved  methods  of  examination  and  treatmen  t  of  diseases  of  the  nose,  throat, 
and  larynx.  The  plan  pursued  is  one  well  adapted  to  the  needs  of  the  general  practitioner." — American  Medical 
yournal. 

JONES,  AURAL  ATLAS. 

An  Atlas  of  Diseases  of  the  Membrana  Tympani.  Being  a  Series  of  Colored 
Plates,  containing  62  Figures.  With  appropriate  Letter-press  and  Explanatory 
Text.  By  H.  Macnaughton  Jones,  m.d..  Surgeon  to  the  Cork  Ophthalmic  and 
Aural  Hospital.     4to.  Price  §4.00. 

"  The  cases  are  well  selected,  the  drawings  executed  from  life,  highly  artistic  and  very  conscientious,  and  the 
commentaries  indicate  familiarity  with  the  subject  and  good  judgment  in  dealing  with  it." — British  Medical 
yournal. 

BY   SAME    AUTHOR. 

AURAL  SURGERY. 

A  Practical  Hand-book  on  Aural  Surgery.  Illustrated.  Second  Edition,  Re- 
vised and  Enlarged,  with  new  Wood  Engravings,     i2mo.     Cloth.       Price  $2.75 

JONES,  SIEVEKING  AND  PAYNE,  PATHOLOGICAL  AN- 
ATOMY. 

A  Manual  of  Pathological  Anatomy.  By  C.  Handfield  Jones,  m.d.,  and 
Edward  H.  Sieveking,  m.d..  Physician  to  St.  Mary's  Hospital.  A  New  En- 
larged Edition.  Edited  by  J.  F.  Payne,  m.d.,  Lecturer  on  Morbid  Anatomy  at 
St.  Thomas'  Hospital.     With  Numerous  Illustrations.     Demi  8vo.     Price  $5.50. 

JONES,  ON  SIGHT  AND  HEARING. 

The  Defects  of  Sight  and  Hearing,  their  Nature,  Causes,  and  Prevention.  By 
T.  Wharton  Jones,  m.d.    Second  Edition.     i6mo.  Price  .50. 

KIRBY,  ON   PHOSPHORUS.     Fifth  Edition. 

Phosphorus  as  a  Remedy  for  Functional  Diseases  of  the  Nervous  System. 
By  E.  A.  KiRBY,  m.d.     Fifth  Edition.     Svo.  Price  gi.oo 

KOLLMEYER,  KEY  TO  CHEMISTRY. 

Chemia  Coartata,  or  Key  to  Modern  Chemistry.  By  A.  H.  Kollmeyer,  m.d. 
With  Numerous  Tables,  Tests,  etc.  Price  $2.25 

KIRKE,  PHYSIOLOGY.     Revised  and  Enlarged. 

A  Hand-book  of  Physiology.  By  Kirke.  Tenth  London  Edition.  By  W. 
Morrant  Baker,  m.d.     420  Illustrations.     Now  Ready.  Price  ^5.00 

"  This  is  undoubtedly  the  best  work  for  students  on  Physiologj'  extant." — Cincinnati  Med.  News. 


24  PRESLEY  BLAKISTON'S 

KANE,  THE  OPIUM,  MORPHINE  AND  SIMILAR  HABITS. 

Drugs  that  Enslave.  The  Opium,  Morphine,  Chloral,  Hashisch  and  Similar 
Habits.     By  H.  H.  Kane,  m.d.,  of  New  York.     With  Illustrations.     Price  $1.50 

"  It  contains  a  large  amount  of  information  collected  with  much  labor  and  presented  in  a  systematic  manner. 
The  subject  of  the  chloral  habit  has  not  been  investigated  by  any  one,  we  believe,  so  thoroughly  as  Dy  Dr.  Kane." 
— Medical  Record. 

"  It  deserves  to  be  read  by  those  who  feel  an  interest  in  discouraging  the  use  of  these  dangerous  drugs.  The 
book  is  embellished  by  an  excellent  phototype  frontispiece  of  Laocoon." — Ajnerican  Journal  of  Pharmacy. 

"A  work  of  more  than  ordinary  ability  and  careful  research.  .  .  .  For  the  first  time,  reliable  statistics  on 
the  use  of  chloral  are  classified  and  published,  .  .  .  and  it  is  shown  that  the  use  of  (MaxsX  causes  a  more 
complete  and  rapid  ruin  of  mind  and  body  than  either  opium  or  morphine." — Druggists'  Circular  and  Gazette. 

KIDD,  THERAPEUTICS. 

The  Laws  of  Therapeutics ;  or,  the  Science  and  Art  of  Medicine.  By  Joseph 
KiDD,  M.D.     i2mo.     Cloth.  Price  $1.25. 

Dr.  Joseph  Kidd,  who,  "by  the  way,  was  Lord  Beaconsfield's  medical  adviser,  and 
an  eminent  physician  of  the  regular  school,  briefly  but  clearly  sketches  the  history  of 
medicine  from  the  earliest  period.  He  shows  that  the  chief  mistakes  have  been 
made  through  deference  to  theory  and  negligence  of  the  teachings  of  facts.  Thence 
he  passes  to  an  assertion  of  the  value  of  the  homoeopathic  principle  of  similia  simili- 
bus  in  the  treatment  of  many  diseases.  He  is  not  a  follower  of  Hahnemann,  and 
does  not  believe  in  iniinitessimal  doses,  but  he  claims,  and  enforces  his  position  by 
the  citation  of  cases  in  his  own  practice,  that  the  homoeopathic  principle  has  performed 
wonders  where  that  of  his  own  school  was  much  less  successful. 

"  Dr.  Kidd  acknowledges  two  laws — that  oi contraria  contrariis  anisiinilia  similibus ;  but  the  cases  he  gives 
in  his  chapter  on  ars  medica  show  that,  like  a  sensible  practitioner,  he  does  not  allow  himself  blindly  to  follow 
either  the  one  or  the  other,  but  seeks  out  the  cause  of  disease,  and  tries  by  rational  measures  to  remove  it.  The 
cases  are  the  most  valuable  part  of  the  book." — London  Practitioner . 

LEGG,  ON  THE  URINE. 

Practical  Guide  to  the  Examination  of  the  Urine,  for  Practitioner  and  Student. 
By  J.  WiCKHAM  Legg,  m.d.     Fifth  Edition,  Enlarged.     Illustrated.     i2mo. 

Price  .75 

This  little  work  is  intended  to  supply  the  Physician  or  Student  with  a  concise  guide 

to  the  recognition  of  the  different  characteristics  of  the  urine,  and  though  small  and 

well  adapted  to  the  pocket,  contains,  probably,   everything  that  could  be  gleaned 

from  a  larger  work. 

LEARED,  IMPERFECT  DIGESTION. 

The  Causes  and  Treatment  of  Impeifect  Digestion.  By  Arthur  Leared,  m.d. 
The    7th    Edition.     Revised  and  Enlarged.     i2mo.  Price  $2.00 

LIEBREICH,  ATLAS  OF  OPHTHALMOSCOPY. 

An  Atlas  of  Ophthalmoscopy,  containing  12  Full-page  Chromo-Lithographic 
Plates,  with  59  Figures.  By  R.  Liebreich,  m.d.  Second  Edition,  Enlarged. 
Large  Quarto.  Price  $12.00 

LIVEING,  ON  SICK  HEADACHE. 

Megrim,  or  Sick  Headache  and  Some  Allied  Disorders.  By  Edward  Live- 
ING,  M.D.     With  Plates,  Tables,  etc.     8vo.  Price  $5.50 

LEBER  AND  ROTTENSTEIN,  DENTAL  CARIES. 

Dental  Caries  and  Its  Causes.  An  Investigation  into  the  Influence  of  Fungi 
in  the  Destruction  of  the  Teeth.  By  Drs.  Leber  and  Rottenstein.  Illustrated. 
8vo.  Price  ,$1.25 

"  The  work  gives  the  result  of  patient  observation,  presents  the  deductions  of  its  authors  with  a  perspicuity  and 
modesty  calculated  to  secure  for  its  positions  a  thoughtful  consideration.  We  heartily  commend  it  as  an  educa- 
tional work." — Dental  Cosm.os. 


PUBLICA  TIONS.  25 


I.EWIN,  ON   SYPHILIS. 

The  Treatment  of  Syphilis.  By  Dr.  George  Lewin,  of  Berlin.  Translated 
by  Carl  Proegler,  m.d.,  and  E.  H.  Gale,  m.d.,  Surgeons  U.  S.  Army.  Illus- 
trated.    i2mo.  Price  $1.25 

"  When  such  authorities  as  Dr.  Drysdale  (as  we  quoted  a  few  weeks  ago)  condemn  the  use  of  mercury  in  syphilis 
as  "  too  dangerous,"  while,  on  the  other  hand,  eminent  surgeons,  such  as  Professor  Gross,  will  not  treat'a  case 
without  that  drug,  general  practitioners  will  gladly  welcome  any  media  ■via  which  gives  us  all  the  good  effects  of 
mercurials  without  any  danger  of  their  ill  results  appearing.  This  is  what  is  accomplished  by  Dr.  Lewin." — 
Philadelphia  hRdical  and  Surgical  Reporter. 

LIZARS,  ON  TOBACCO. 

The  Use  and  Abuse  of  Tobacco.     By  John  Lizars,  m.d.  i2mo.  Price 

LONGLEY,  POCKET  MEDICAL  LEXICON. 

"  Students'  Pocket  Medical  Dictionary,  Giving  the  Correct  Definition  and  Pro- 
nunciation of  all  Words  and  Terms  in  General  Use  in  Medicine  and  the  Collate- 
ral Sciences,  with  an  Appendix,  containing  Poisons  and  their  Antidotes,  Abbre- 
viations Used  in  Prescriptions,  and  a  Metric  Scale  of  Doses.  By  Elias  Longley. 
24mo.  Price,  Cloth,  ^i.oo  ;  Tucks  and  Pocket  ^1.25 

This  is  an  entirely  new  Medical  Dictionary,  containing  some  300  compactly 
printed  24mo  pages,  very  carefully  prepared  by  the  author,  who  has  had  much  ex- 
perience in  the  preparation  of  similar  works,  assisted  by  the  Professors  of  Chemistry 
and  of  Botany  in  one  of  our  leading  medical  colleges. 


"  This  little  book  will  be  welcomed  by  students  in 
medicine  and  pharmacy  as  a  convenient  pocket  com- 
panion, giving  the  pronunciation,  acceptation,  and 
definition  of  medical,  pharmaceutical,  chemical  and 
botanical  terms." — American  yournal  of  Pharmacy. 

"  It  would  seem  to  be  just  the  book  for  dental  and 
medical  students." — Dental  Advertiser. 


"  It  is,  we  believe,  also  the  only  lexicon  in  existence 
in  v/hich  the  pronunciation  of  words  is  fully  and  dis- 
tinctly marked." — Canada  Medical  Revie'w. 

"  This  is  a  very  compact  a,nd  complete  little  diction- 
ary. We  commend  it  as  particularly  useful  to  students." 
— J^ew  York  Medical  yournal. 


MAYNE,  MEDICAL  DICTIONARY.     Fifth  Edition. 

A  Medical  Vocabulary,  Being  an  Explanation  of  all  Terms  and  Phrases  used 
in  the  Various  Departments  of  Medical  Science  and  Practice,  Giving  their  Deri- 
vation, Meaning,  Application,  and  Pronunciation.  Intended  specially  as  a  Book 
of  Reference  for  the  Student.  By  Drs.  R.  G.  and  J.  Mayne.  Fifth  Edition. 
Revised  and  Enlarged.     Cloth.  Price  $4.00 

MEDICAL   REGISTER. 

A  Monthly  Journal  Devoted  to  the  Literature  of  Medicine  and  Allied  Sciences. 
Containing  Critical  Reviews,  Book  Notices,  Miscellaneous  News,  and  complete 
Bibliographical  Lists  of  all  New  Books  published  on  Medical  and  Scientific 
Subjects.  Terms,  per  Annum,  $1.00 

An  invaluable  Monthly  Reference  List  for  Librarians,  Professors,  Specialists,  and 
all  wishing  to  keep  acquainted  with  the  Medical  Literature  of  the  day. 

MACDONALD,      MICROSCOPICAL      EXAMINATION      OF 
WATER. 

A  Guide  to  the  Microscopical  Examination  of  Drinking  Water.  By  J.  D. 
Macdonald,  m.d.  With  Twenty  Full-page  Lithographic  Plates,  Reference 
Tables,  etc.     8vo.  Price  ^2.75 

"The  volume  is  an  excellent  hand-book  and  will  greatly  facilitate  the  study  of  the  subject." — Popular  Science 

Monthly. 

MACEWEN,  ON  OSTEOTOMY. 

An  Inquiry  into  the  /Etiology  and  Pathology  of  Knock-knee,  Bow-leg  and 
other  Osseous  Deformities  of  the  Lower  Limbs.  By  Wm.  Macewen,  m.d.  Il- 
lustrated.    8vo.  Price  %\.oo 


26  PRESLE Y  BLAKISTON'S 

MACKENZIE,  ON  THE  THROAT  AND  NOSE. 

Including  the  Pharynx,  Larynx,  Trachea,  CEsophagus,  Nasal  Cavities,  and 
Keck.  By  Morell  Mackenzie,  m.d.,  London,  Senior  Physician  to  the  Hos- 
pital for  Diseases  of  the  Chest  and  Throat,  Lecturer  on  Diseases  of  the  Throat 
at  London  Hospital  Medical  College,  etc.,  etc. 

Vol.  L     Including  the  Pharynx,  Larynx,  Trachea,  etc.     112  Illustrations. 

Now  Ready.  Price,  Cloth,  $4.00  ;  Leather,  $5.00 

Vol.  II.     Including  the  CEsophagus,  Nasal  Cavities,  Neck,  etc'    Illustrated. 

Ill  Preparation. 

Author's  Edition,  issued  under  his  supervision,  containing  all  the  original  Wood 
Engravings,  and  the  essay  on  "  Diphtheria,  Its  Causes,  Nature,  and  Treatment,"  for- 
merly published  separately.  Each  volume  sold  separately;  purchasers  of  Volume  I. 
will  receive  early  information  of  date  of  issue  and  price  of  Volume  II.,  upon  sending 
their  address  to  the  publishers. 

"We  have  long  felt  the  want  of  a  thoroughly  practical  and  systematic  treatise  on  diseases  of  the  throat 
End  nasal  passages.  Admirable  essays  have  from  time  to  time  appeared  ;  no  standard  work  has  been  written. 
Any  one  familiar  with  laryngoscopic  work  must  appreciate  the  valuable  addition  now  made  to  this  special 
department  in  the  work  before  us.  The  entire  work  will  include  the  consideration  of  affections  of  the  pharj-nx, 
larynx,  trachea,  oesophagus,  nasal  cavities,  and  neck.  The  matter  now  presented  complete  for  the  first  time  is 
the  result  of  the  author's  large  and  unrivaled  experience,  both  in  hospital  and  private  practice,  extending  over 
a  period  of  twenty  years.  There  can  be  but  one  verdict  of  the  profession  on  this  manual — it  stands  without  any 
competitor  in  medical  literature,  as  a  standard  work  on  the  organs  it  professes  to  treat  of." — Dublin  jfouryzal. 

"  It  is  both  practical  and  learned  ;  abundantly  and  well  illustrated  ;  its  descriptions  of  disease  are  graphic,  and 
the  diagnoses  the  best  we  have  anywhere  seen.  To  give  examples  of  the  thoroughness  of  Dr.  Mackenzie's  book, 
we  may  cite  the  chapter  on  diphtheria,  which  embraces  47  pages.  The  chapter  on  non-malignant  tumors  of  the 
larynx  would  appear  to  be  absolutely  exhaustive.  Nowhere  else  have  we  seen  so  elaborate  a  statement  of  the  sub- 
ject. We  can  predict  for  this  work  a  high  position,  and  congratulate  its  distinguished  author  upon  its  appear- 
ance."— Philadelphia  Medical  Times. 

BY   SAME  AUTHOR. 

THE  PHARMACOPOEIA  of  the   Hospital  for  Diseases   of  the 
Throat  and  Nose. 

The  Fourth  Edition,  much  enlarged,  containing  250  Formulae,  with  Directions 
for  their  Preparation  and  Use.     i6mo.  Price  ^1.25 

GROWTHS  IN  THE  LARYNX. 

Their  History,  Causes,  Symptoms,  etc.  With  Reports  and  Analysis  of  one 
Hundred  Cases.     With  Colored  and  Other  Illustrations.     8vo.  Price  $2.00 

MACNAMARA,  DISEASES  OF  THE  EYE. 

A  Manual  of  the  Diseases  of  the  Eye.  By  C.  Macnamara,  m.d.  Fourth 
Edition,  Carefully  Revised ;  with  Additions  and  Numerous  Colored  Plates,  Dia- 
grams of  Eye,  Wood-cuts,  and  Test  Types.     Demi  8vo.  Price 

"As  a  book  of  ready  reference  on  diseases  of  the  eye  it  has  no  superior,  and  we  may  safely  say,  no  equal  in  our 
language." — Cincituiati  Lancet  and  Observer. 

BY   SAME   AUTHOR. 

ON  THE  BONES  AND  JOINTS. 

Lectures  on  Diseases  of  the  Bones  and  Joints.     Second  Edition.      Demi  8vo. 

Price  $4.25 

MADDEN,  HEALTH    RESORTS. 

Health  Resorts  for  the  Treatment  of  Chronic  Diseases.  A  Hand-Book,  the 
result  of  the  author's  ov/n  observations  during  several  years  of  health  travel  in 
many  lands,  containing  also  remarks  on  climatology  and  the  use  of  mineral 
waters.     By  T.  M.  Madden,  m.d.     8vo.  Price  $2.50 

"  Rarely  have  we  encountered  a  book  containing  so  much  information  for  both  invalids  and  pleasure  seekers." 
—  The  Sanitarian. 

MEDICAL  REGISTER. 

Directory  of  Physicians  in  Philadelphia.     Octavo.  Cloth,  $1.00 


PUB  Lie  A  TIONS.  27 


MARSHALL  &  SMITH,  ON  THE  URINE. 

The  Chemical  Analysis  of  the  Urine.  By  John  Marshall,  m.d.,  and  Edgar 
F.  Smith,  m.d.,  of  the  Chemical  Laboratory,  Medical  Department,  University  of 
Pennsylvania.     Illustrated  by  Phototype  Plates.  i2mo.  Price  f  i.oo 

MARSHALL,  ANATOMICAL  PLATES; 

Or  Physiological  Diagrams.     Life  Size  (7  by  4  feet)  and  Beautifully  Colored. 
By  John  Marshall,  f.r.s.     An  Entirely  New  Edition,  Revised  and  Improved, 
Illustrating  the  Whole  Human  Body. 
The  Set,  Eleven  Maps,  in  Sheets,  Price  $5o.cx) 

"  "  handsomely  Mounted  on  Canvas,  with 

Rollers,  and  Varnished,  Price  ^80.00 
An  Explanatory  Key  to  the  Diagrams,  Price  .50 

Dr.  Marshall's  Plates,  from  their  size  and  perfection  of  drawing  and  coloring,  excel 
any  diagrams  that  have  been  published.  They  have  proved  invaluable  in  Medical 
Schools  and  Lecture  Rooms.  The  low  price  at  which  they  are  offered  brings  them 
within  reach  of  all. 

No.  I.  The  Skeleton  and  Ligaments.  No.  2.  The  Muscles,  Joints,  and  Animal  Mechanics.  No.  3.  The  Vis- 
cera in  Position— The  Structure  of  the  Lungs.  No.  4.  The  Organs  of  Circulation.  No.  5.  The  Lymphatics  or 
Absorbents.  No.  6.  The  Digestive  Organs.  No.  7.  The  Brain  and  Nerves.  No.  8.  The  Organs  of  the  Senses 
and  Organs  of  the  Voice,  Plate  i.  No.  9.  The  Organs  of  the  Senses,  Plate  2.  No.  10.  The  Microscopic 
Structure  of  the  Textures,  Plater.     No.  11.  The  Microscopic  Structure  of  the  Textures,  Plate  2. 

MARSDEN,  ON  CANCER. 

A  New  and  Successful  Mode  of  Treating  Certain  Forms  of  Cancer.  By  Alex- 
ander Marsden,  m.d.     Second  Edition.     Colored  Plates.     8vo.        Price  ^3.00 

MARTIN,  MICROSCOPIC  MOUNTING. 

A  Manual  of  Microscopic  Mounting.  With  Notes  on  the  Collection  and  Ex- 
amination of  Objects,  and  upwards  of  150  Illustrations.  By  John  H.  Martin. 
Second  Edition,  Enlarged.     Svo.  Price  $2.75 

MORRIS,  ON  THE  JOINTS. 

The  Anatomy  of  the  Joints  of  Man.  Comprising  a  Description  of  the  Liga- 
ments, Cartilages,  and  Synovial  Membranes;  of  the  Articular  Parts  of  Bones, 
etc.  By  Henry  Morris,  f.r.c.s.  Illustrated  by  44  Large  Plates  and  Numerous 
Figures,  many  of  which  are  Colored.     Svo.  Price  ^5.50 

MUTER,    MEDICAL   AND    PHARMACEUTICAL   CHEMIS- 
TRY. 

An  Introduction  to  Pharmaceutical  and  Medical  Chemistry.  Part  One. — 
Theoretical  and  Descriptive.  Part  Two. — Practical  and  Analytical.  Arranged 
on  the  principle  of  the  Course  of  Lectures  on  Chemistry  as  delivered  at,  and  the 
Instruction  given  in  the  Laboratories  of,  the  South  London  School  of  Pharmacy. 
By  John  Muter,  m.d.,  President  of  the  Society  of  Public  Analysts.  A  Second 
Edition,  Enlarged  and  Rearranged.  The  Two  Parts  bound  in  one  large  octavo 
volume.  Price  $6.00 

Part  Two. — Practical  and  Analytical.  Bound  Separately,  for  the  Special  Con- 
venience of  Students.     Large  Svo.     Cloth.  Price  $2.50 

MAC  MUNN,  THE  SPECTROSCOPE. 

The  Spectroscope  in  Medicine.  By  Chas.  A.  Mac  Munn,  m.d.  With  3 
Chromo-lithographic  Plates  of  Physiological  and  Pathological  Spectra,  and  13 
Wood  Cuts.     Svo.  Price  $3.00 

"  This  book  is,  without  question,  the  best  that  has  yet  been  published  on  the  subject ;  to  those  not  familiar  with 
Physiological  Spectroscopy  it  will  prove  interesting,  while  to  those  who  are  worlang  in  this  field  it  is  a  neces' 
sity." — ye-u)  York  Medical  yotirnal. 


28 


PRESLEY  BLAKISTON'S 


MASON,  ON  THE  FACE. 

The  Surgery  of  the  Face.     By  Francis  Mason,  f.r.c.s.     With  loo  Illustra- 
tions, showing  the  various  operations  performed.     8vo.  Price  $2.25 

Dr.  Mason  has  for  many  years  taken  considerable  interest  in  the  surgery  of  the 
face,  mouth,  throat,  and  contiguous  parts,  collecting  several  thousand  cases  of  the 
different  operations  having  special  reference  to  these  regions,  which,  from  their 
conspicuousness,  form  a  very  important  part  of  the  human  body. 

MAUNDER,  OPERATIVE    SURGERY. 

Operative  Surgery.     Adapted  to  the  Living  and  Dead  Subject.     By  C.  F. 
Maunder,  f.r.c.s.     Second  Edition,  with  One  Hundred  and  Sixty-four  En- 


gravings on  Wood. 


THE  ARTERIES. 


Price  I2.25 


BY  SAME   AUTHOR. 


Surgery   of   the    Arteries,    including    Aneurisms,    Wounds,    Hemorrhages, 
Twenty-seven  Cases  of  Ligatures,  Antiseptic,  etc.  With  Illustrations.  Price  $1.50 


MAXON,  ON  PRACTICE. 

The  Practice  of  Medicine.     By  Edwin  R.  Maxon,  m.d. 


Bvo.       Price  txoo 


yiPCi^,  THE  THERAPEUTIC  FORCES; 

Or,  The  Action  of  Medicine  in  the  Light  of  the  Doctrine  of  Conservation  of 
Force.     By  Thomas  J.  Mays,  m,d.     i2mo.  Price  $1.25 

MEADOWS,  ON  MIDWIFERY. 

A  Text-Book  of  Midwifery.  Including  the  Signs  and  Symptoms  of  Preg- 
nancy, Obstetric  Operations,  Diseases  of  the  Puerperal  State,  etc.  By  Alfred 
Meadows,  m.d.  Third  American,  from  Fourth  London  Edition.  Revised  and 
Enlarged.     With  145  Illustrations.     Bvo.  Price  $2.00 


"  It  is  with  great  gratification  that  we  are  enabled 
to  class  Dr.  Meadows'  Manual  as  a  rare  exception, 
and  to  pronounce  it  an  accurate,  practical,  and  cred- 
itable work,  and  to  unhesitatingly  recommend  it  to 
both  student  and  practitioner." — Ainerican  yournal 
of  Obstetrics. 

"  We  cannot  but  feel  that  every  teacher  of  Obstet- 
rics has  good  cause  to  congratulate  himself  on  being 
able  to  put  in  the  hands  of  the  student  a  book  which 
contains  so  much  valuable  and  reliable  information." 
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"  On  all  questions  of  treatment,  whether  by  medi- 
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ative appliances,  this  treatise  is  as  satisfactory  as  a 
work  of  manual  size  could  be  :  students  and  practi- 
tioners can  hardly  do  better  than  adopt  it  as  their 
vade  mecum." — The  Practitioner. 

"  The  systematic  arrangement  of  subjects,  and  the 
concise,  practical  style  in  which  it  is  written,  make 
the  work  especially  valuable  as  a  student's  manual." 
Chicago  Medical  Examiner, 


MEARS,  PRACTICAL  SURGERY. 

Practical  Surgery.  Including  :  Part  i. — Surgical  Dressings  ;  Part  11. — Band- 
aging ;  Part  in. — Ligations;  Part  iv. — Amputations.  With  227  Illustrations. 
By  J.  EwiNG  Mears,  m.d..  Demonstrator  of  Surgery  in  Jefferson  Medical  Col- 
lege, and  Professor  of  Anatomy  and  Clinical  Surgery  in  the  Pennsylvania  Col- 
'  ~         "  "  Price  $2.00 

"It  contains  a  great  deal  of  information  upon  the 
subjects  of  which  it  treats,  in  a  convenient  and  con- 
densed form.  Each  division  is  well  illustrated,  thereby 
rendering  the  text  doubly  clear." — New  York  Medical 
Record. 


lege  of  Dental  Surgery.     i2mo. 

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preface." — Cincinnati  Lancet  and  Clinic. 


MILLER,  ON  ALCOHOL. 

Alcohol.    Its  Place  and  Power.    By  James  Miller,  f.r.c.s.   i2mo.    Price  .50 

MILLER  &  LIZARS,  ALCOHOL  AND  TOBACCO. 

Alcohol.  Its  Place  and  Power.  By  James  Miller,  f.r.c.s.  ;  and,  Tobacco, 
Its  Use  and  Abuse.  By  John  Lizars,  m.a.  The  two  essays  in  one  volume. 
i2mo.  Price  $1.00 


PUB  Lie  A  TIONS. 


29 


MENDENHALL,  VADE  MECUM. 

The  Medical  Student's  Vade  Mecum.  A  Compend  of  Anatomy,  Physiology, 
Chemistry,  The  Practice  of  Medicine,  Surgery^,  Obstetrics,  etc.  By  George 
Mendenhall.  m.d.     Eleventh  Edition.     224  Illustrations.     8vo.         Price  ^2.00 

MEIGS  AND  PEPPER,  DISEASES  OF  CHILDREN. 

A  Practical  Treatise  on  the  Diseases  of  Children.  By  J.  Forsyth  Meigs,  m.d.. 
Fellow  of  the  College  of  Physicians  of  Philadelphia,  etc.,  etc.,  and  William 
Pepper,  m.d..  Physician  to  the  Philadelphia  Hospital,  Provost  University  of 
Pennsylvania.  Seventh  Edition,  thoroughly  Revised  and  Enlarged.  A  Royal 
Octavo  Volume  of  over  1000  pages.  Price,  Cloth,  $6.00;  Leather,  ^7.00 

"  With  the  recent  additions  it  may  safely  be  pronounced  one  of  the  best  and  most  comprehensive  tvorks  on  Dis- 
eases of  Children." — New  York  Medical  jfournal. 

"  Must  be  regarded  as  the  most  complete  work  on  Diseases  of  Children  in  our  language." — Edinburgh  Medical 
yournal. 

"  We  have  seldom  met  with  a  text-book  so  complete,  so  just  and  so  readable  as  the  one  before  us." — American 
jfournal  of  Obstetrics. 

MATHIAS,  LEGISLATIVE  MANUAL. 

A  Rule  for  Conducting  Business  in  Meetings  of  Societies,  Legislative  Bodies, 
Town  and  Ward  Meetings,  etc.  By  Benj.  Mathias,  a.m.  Sixteenth  Edition. 
l6mo.  Price  .50 

MORTON,  REFRACTION  OF  EYE. 

The  Refraction  of  the  Eye.  Its  Diagnosis  and  the  Correction  of  its  Eriors. 
With  Chapter  on  Keratoscopy.     By  A.  Stanford  Morton,  m.b.,  f.r.c.s.     i2mo. 

Price  ^i.oo 

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ena observed,  which  is  at  once  scientific  and  elementary."— Edinburgh  Medical  Journal. 

OVERMAN,  MINERALOGY. 

Practical  Mineralogy,  Assaying,  and  Mining,  with  a  Description  of  the  Useful 
Minerals,  etc.  By  Frederick  Overman,  Mining  Engineer,  nth  Edition. 
i2nio.     Cloth.  Price  gi.oo 

OGSTON,  MEDICAL  JURISPRUDENCE. 

Lectures  on  Medical  Jurisprudence.  By  Drs.  Francis  and  Francis  Ogston, 
Jr.    With  Copper-plate  Illustrations.     8vo.  Price  ^6.00 

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ing all  that  the  distinguished  author  promised  for  it." — American  yotcrnal  of  Medical  Science. 

OLDBERG,  PRESCRIPTION  BOOK.     300  New  Prescriptions. 

Three  Hundred  Prescriptions,  Selected  Chiefly  from  the  Best  Collections  of 

Formulee  used  in  Hospital  and  Out-patient-practice,  with  a  Dose  Table,  and  a 

Complete  Account  of  the  Metric  System.     By  Oscar  Oldberg,  phar.  d..  Late 

Medical  Purveyor,  United  States  Marine  Hospital  Service;  Professor  of  Materia 

Medica,  National   College  of  Pharmacy,  Washington,  D.  C. ;  Member  of  the 

American  Pharmaceutical  Association,  and  of  the  Sixth  Decennial  Committee 

of    Revision    and    Publication    of  the    Pharmacopoeia    of  the    United    States. 

i2mo.  Price  $1.50 

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Dose  Table  includes  nearly  all  of  the  remedies  that  have  a  place  in  the  current 

Materia  Medica. 


30  PRESLE  V  BLAKISTON' S 


BY   SAME   AUTHOR. 

THE  UNOFFICIAL  PHARMACOPCEIA. 

Comprising  over  700  Popular  and  Useful  Preparations,  not  Official  in  the 
United  States,  of  the  various  Elixirs,  Fluid  Extracts,  Mixtures,  Syrups,  Tinct- 
ures, Ointments,  Wines,  etc,  etc.,  in  constant  demand  throughout  the  country. 
Thick  i2mo.     503  pp.     Half  Morocco.  Price  $3.50 

So/d  by  Subscriptioti. 
B^»It  Will  Prove  a  Useful  Supplement  to  the  Pharmacopceia  of  the 
United  States  ;  the  aim  has  been  to  make  it  as  complete  as  practicable.  The  form- 
ulae can,  with  a  minimum  of  labor,  be  used  with  any  system  of  weights  and  meas- 
ures. The  virtual  adoption  of  the  metric  system  in  the  forthcoming  Pharmacopoeia 
of  the  United  States  will  account  for  the  prefei-ence  given  to  that  system  in  this  vol- 
ume, which,  however,  does  not  prevent  the  ready  use  of  the  book  with  apothecaries' 
weights  and  measures.  An  extended  account  of  the  metric  system  has  been  given, 
accompanied  by  full  tables  of  equivalents.  The  sources  from  which  the  formula 
have  been  gathered  are  believed  to  be  the  best.  They  include  the  Pharmacopoeias 
of  England,  Germany,  France  and  Sweden.  The  book  is  practically  equivalent  to 
the  possession  of  these  various  Pharmacopoeias,  and  the  formula  were  selected  with 
reference  to  their  popularity,  usefulness,  and  interesting  character. 

"  This  volume  is  one  of  the  most  practical  and  valuable  contributions  to  Pharmaceutical  work  of  recent  publica- 
tion. It  has  received  high  commendation  from  many  of  our  best  pharmacists  " — Lazeil,  Marsh  &"  Gardiner, 
Wholesale  Druggists,  New  York  City. 

OTT,  ACTION  OF  MEDICINES. 

The  Action  of  Medicines.  By  Isaac  Ott,  m.d.,  late  Demonstrator  of  Experi- 
mental Physiology  in  the  University  of  Pennsylvania.  With  22  Illustrations. 
8vo.  Price  $2.00 

"  This  work  is  the  only  one  in  the  English  language  which  can  offer,  with  any  degree  of  completeness,  that  assist- 
ance and  instruction  so  essential  to  the  correct  and  successful  study  of  pharmacology.  Filling,  as  it  does,  this  gap 
in  medical  literature,  we  have  a  work  which  cannot  fail  to  be  of  the  greatest  value  to  students. 

"From  the  pen  of  a  man  himself  no  novice  in  the  subject  of  which  he  treats,  it  bears  upon  it  the  impress  of  relia- 
bility, due  to  the  author's  own  experience,  a  virtue  too  often  wanting  in  mere  compilations  of  the  works  of  oth- 
ers."— American  journal  of  Medical  Sciences. 

PAGET,  SURGICAL  PATHOLOGY. 

Lectures  on  Surgical  Pathology,  Delivered  at  the  Royal  College  of  Surgeons. 
By  James  Paget,  f.r.s.  Third  Edition.  Edited  by  William  Turner,  m.d. 
With  Numerous  Illustrations.     8vo.  Price,  Cloth,  $7.00;  Leather,  ^8.00 

PARKES,  PRACTICAL  HYGIENE.     Sixth  Edition. 

A  Manual  of  Practical  Hygiene.  By  Edward  A.  Parkes,  m.d.  The  Sixth 
Revised  and  Enlarged  Edition.     With  Many  Illustrations.     8vo.        Price  g6.oo 

"Altogether  it  is  the  most  complete  work  on  Hygiene  which  we  have  seen." — New  York  Medical  Record. 

"We  find  that  it  never  fails  to  throw  light  on  any  hygienic  question  which  may  be  -proposed."— Boston  Medi- 
cal and  Surgical  yourncM. 

"We  commend  the  book  heartily  to  all  needing  instruction  (and  who  does  not),  in  Hygiene  " — Chicago  Mtdi- 
cal  yournal. 

PIESSE,  THE  MANUFACTURE  OF  PERFUMERY.    Fourth 
Edition. 

The  Art  of  Perfumery;  or  the  Methods  of  Obtaining  the  Odors  of  Plants,  and 
Instruction  for  the  Manufacture  of  Perfumery,  Dentifrices,  Soap,  Scented  Pow- 
ders, Odorous  Vinegars  and  Salts,  Snuff,  Cosmetics,  etc.,  etc.  By  G.  W.  Septi- 
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32  PRESLE  Y  BLAKISTON  'S 

POWER,  HOLMES,  ANSTIE  AND  BARNES  {Drs.). 

Reports  on  the  Progress  of  Medicine,  Surgery,  Physiology,  Midwifery,  Dis- 
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PURCELL,  ON  CANCER. 

Cancer.  Its  Allies  and  other  Tumors,  with  Specia  Reference  to  their  Medi- 
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RADCLIFFE,  ON  EPILEPSY. 

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ROBERTS,  MANUAL  OF  MIDWIFERY. 

The  Student's  Guide  to  the  Practice  of  Midwifery.  By  D.  Lloyd  Roberts, 
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RIGBY  AND  MEADOWS,  OBSTETRIC  MEMORANDA. 

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PIGGOTT,  ON  COPPER.  . 

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PRINCE,  ORTHOPEDIC  SURGERY. 

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33 


ROBERTS,  PRACTICE  OF  MEDICINE.     Fourth  Edition. 

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RINDFLEISCH,  PATHOLOGICAL  HISTOLOGY. 

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ROYLE  AND  HARLEY,  MATERIA  MEDICA.    Sixth  Edition. 

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Outlines  of  Practical  Histology  ;  being  the  Notes  of  the  Course  of  Practical 
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SANKEY,  MENTAL  DISEASES. 

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34  PRESLEY  BLAKISTON'S 

SANDERSON  AND  FOSTER,  THE    PHYSIOLOGICAL  LA- 
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Medical  Journal. 

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SANSOM,  PHYSICAL  DIAGNOSIS.     Third  Edition  just  ready. 

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ON    CHLOROFORM. 

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SMITH,  MANUAL  OF  GYNiECOLOGY. 

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DYSMENORRHCEA.    Just  Issued. 

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SMITH,  RINGWORM. 

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SMITH,  ON  NURSING. 

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SMITH,  ON  CHILDREN. 

Clinical  Studies  of  Diseases  in  Children. 

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MEDICAL  HERESIES,  HISTORICALLY  CONSIDERED. 

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SAVAGE,  FEMALE  PELVIC  ORGANS.    Author's  Edition. 

The  Surgery,  Surgical  Pathology  and  Surgical  Anatomy  of  the  Female  Pelvic 
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STOCKEN,  DENTAL  MATERIA  MEDICA.     Third  Edition. 

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35  PRESLEY  BLAKISTON'S 

SEWELL,  DENTAL  ANATOMY  AND  SURGERY. 

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"  A  valuable  book  for  the  general  Practitioner  who  "  It  will  be  found  useful  to  the  general  Practitioner  in 

fe  in  want  of  a  practical  manual  relating  especially  to        the  management  of  many  incidental  affections  connected 
diseases  of  the  teeth." — Medical  Brief.  with  the   teeth  and   mouth,  which  cannot  always  be 

handed  over  to  the  specialist." — Pacific  Med.  journal. 

STILLE,  ON  MENINGITIS. 

Epidemic  Meningitis,  or  Cerebro-spinal  Meningitis.  By  Alfred  Stille,  m.d., 
Professor  of  Practice  at  the  University  of  Pennsylvania.     8vo.  Price  $2.00 

"  The  name  of  the  author  is  a  sufficient  guarantee  that  this  monograph  is  elegant  in  style,  exhaustive  of  its  sub- 
ject and  rich  with  practical  suggestions.'' — Philadelphia  Medical  and  Surgical  Reporter. 

STOKES,  DISEASES  OF  THE  HEART. 

The  Diseases  of  the  Heart  and  Aorta.  By  William  Stokes,  m.d.  Thick 
8vo.  Price  $3.00 

SWAIN,  SURGICAL  EMERGENCIES. 

Surgical  Emergencies:  Concise  Descriptions  of  the  Various  Accidents  and 
Emergencies,  with  Directions  for  their  Treatment.  By  Wm.  Paul  Swain,  f.r. 
C.s.     Eighty-two  Illustrations.     i2mo.  Price  $2.00 

Contents. — Chapter  I.  Injuries  to  the  Head.  II.  Injuries  to  the  Eye.  III.  Injuries  to  the  Mouth, 
Pharynx,  GEsophagus,  and  Larynx.  IV.  The  Chest.  V.  The  Upper  Extremity.  VI.  The  Abdomen.  VII. 
The  Pelvis.  VIII.  The  Lower  Extremity.  IX.  Emergencies  connected  with  Parturition.  X.  Poisoning. 
XI.  Antiseptic  Treatment.     XII.  Apparatus  and  Dressing. 

"  Many  surgeons  will  thank  Dr.  Swain  for  the  trouble  he  has  taken  to  put  them  easily  in  possession  of  this  re- 
fresher of  Aa^  forgotten  knowledge. —  The  Practitioner. 

SWERINGEN,  PHARMACEUTICAL  LEXICON. 

A  Pharmaceutical  Lexicon  or  Dictionary  of  Pharmaceutical  Science.  Contain- 
ing explanations  of  the  various  subjects  and  terms  of  Pharmacy,  with  appropriate 
selections  from  the  Collateral  Sciences.  Formulee  for  Officinal,  Empirical,  and 
Dietetic  Preparations,  etc.,  etc.     By  Hiram.  V.  Sweringen,  m.d.     8vo. 

Price,  Cloth,  IS3.00 ;  Leather,  $4.00 

"  It  is  worthy  of  a  welcome,  and  sure  of  a  ready  recognition  of  its  m.ex\Vi." —London  Pharmaceutical  Journal. 
"  It  will  prove  of  great  service  to  the  pharmaceutical  student,  apprentice,  pharmacist,  druggist  and  physician,  as 
a  book  of  ready  reference  and  as  an  aid  to  the  study  of  scientific  works." — American  Journal  of  Pharmacy. 

THOMPSON,  LITHOTOMY  AND  LITHOTRITY. 

Practical  Lithotomy  and  Lithotrity ;  or,  an  Inquiry  into  the  best  Modes  of 
■Removing  Stone  from  the  Bladder.  By  Sir  Henry  Thompson,  f.r.c.s.,  Emer- 
itus Professor  of  Clinical  Surgery  in  University  College.  Third  Edition.  8vo. 
With  87  Engravings.  Price  $3.50 

"  The  chapters  of  most  interest  are  those  in  which  Bigelow's  operation  is  discussed,  and  the  final  one,  in 
which  is  a  record  of  500  operations  for  stone  in  cases  of  male  adults  under  the  author's  care.  Such  a  table  has 
never  belore  been  compiled  by  any  surgeon." — Lancet. 

BY  same  author. 

URINARY  ORGANS. 

Diseases  of  the  Urinary  Organs.     Clinical  Lectures.     Sixth  London  Edition. 
Enlarged,  with  73  Illustrations.  Price,  Cloth,  $1.25  ;  Paper,  .75 

ON  THE  PROSTATE. 

Diseases  of  the  Prostate.     Their  Pathology  and  Treatment.     Fifth  London 
Edition,     8vo.    With  Numerous  Plates.     Price,  Cloth,  $1.25  ;  Paper,  .75. 

CALCULOUS  DISEASES. 

The  Preventive  Treatment  of  Calculous   Disease,  and  the  Use   of  Solvent 
Remedies.     Second  Edition.     i6mo.  Price  |r.oo 

"Catholic  in  his  investigation  of  the  fruit  of  the  labor  of  others,  cautious  m  all  his  deductions,  rejecting  all  spe- 
cious  theories  in  the  eflFort  to  obtain  practi»lly  useful  results,  as  clever  with  his  pen  as  he  is  with  the  sound  or 
Hthotrite,  one  can  scarcely  wonder  that  he  is  esteemed  the  master  that  he  x^."— American  Journal  qf  Mcdicai 
Science. 


PUBLICA  TIONS. 


37 


THOMPSON,  COUGHS  AND  COLDS. 

The  Causes,  Nature,  and  Treatment  of  Coughs  and  Colds.     By  E.  S,  Thomp- 
son, M.D.     i6mo.  Price  .60 

THOROWGOOD,  MATERIA  MEDICA. 

The  Student's  Guide  to  Materia  Medica.     By  John  C.  Thorowgood,  m.d. 
Illustrated.     318  pages.     i2mo.  Price  $2.00 


BY   SAME  author. 

ON  ASTHMA. 

The  Forms,  Nature,  and  Treatment  of  Asthma. 


i2mo. 


TUSON,  VETERINARY  PHARMACOPCEIA. 

A  Pharmacopoeia,  Including  the  Outlines  of  Materia  Medica  and  Therapeu- 
tics. For  the  Use  of  Students  and  Practitioners  of  Veterinary  Medicine.  By 
Richard  V.  Tuson,  f.c.s.     Third  Edition.     i2mo.  Price  $2.50 

"  Not  only  practitioners  and  students  of  veterinary  medicine,  but  chemists  and  druggists  will  find  that  this 
book  supplies  a  want  in  veterinary  literature." — Druggist  and  Chemist. 

THUDICHUM  ON  THE  URINE.     Second  Edition. 

The  Pathology  of  the  Urine  and  Complete  Guide  to  Analysis.  By  John  L. 
W.   Thudichum,    m.d.      Second   Edition,     Enlarged  and    Illustrated.      8vo. 

Price  $5.00 

"The  treatise  of  Dr.  Thudichum  is  well  known  as  one  of  the  medical  classics  of  the  language,  and  in  com- 
pleteness, thoroughness,  and  originality,  the  volume  before  us  has  few  rivals  in  any  branch  of  our  science.  For 
the  specialist,  for  the  physiological  chemist,  for  the  physiologist,  the  volume  of  Dr.  Thudichum  is  a  sine  qzta 
non,  and  to  such  the  new  edition  must  be  a  most  welcome  guest." — Philadelphia  Medical  Times. 

TROUSSEAU,  CLINICAL  MEDICINE. 

Lectures  on  Clinical  Medicine,  Delivered  at  the  Hotel  Dieu,  Paris,  by  A. 
Trousseau,  Professor  of  Clinical  Medicine  to  the  Faculty  of  Medicine,  Paris, 
etc.,  etc.  Translated  from  the  Third  Revised  and  Enlarged  Edition  by  P.  Vic- 
tor Bazire,  m.d.,  London  and  Paris  ;  and  John  Rose  Cormack,  m.d.,  Edin- 
burgh, F.R.S.,  etc.  With  a  full  Index,  Table  of  Contents,  etc.  2  vols.  8vo. 
Sold  by  Subscription  only.  Price,  Cloth,  $8.00;  Leather,  $10.00 

Sydenham  Edition,  Same  Work.     5  Vols.     8vo.     Large  Print.        Price  $15.00 

Trousseau's  Lectures  have  attained  a  reputation,  both  in  England  and  in  this 

country,  far  greater  than  any  work  of  a  similar  character  heretofore  written.     In 

order  to  bring  the  work  within  the  reach  of  all  the  profession,  the  publishers  now 

issue  an  American  edition,  containing  all  the  lectures  as  contained  in  the  five-vol- 


ume Sydenham  edition,  at  a  much  lower  price, 
favorable  opinions  expressed  of  the  work : — 


Below  are  a  few  only  of  the  many 


"  a  clever  translation  of  Prof.  Trousseau's  admirable 
and  exhaustive  work  ;  the  best  book  of  reference  upon 
the  Practice  of  Medicine." — Indiana  Medical  Gazette. 

"The  great  reputation  of  Prof  Trousseau  as  a  prac- 
titioner and  teacher  of  Medicine  in  all  its  branches, 
renders  tlie  present  appearance  of  his  Clinical  Lectures 
particularly  welcome." — Medical  Press  and  Circular. 

"  It  treats  of  diseases  of  daily  occurrence  and  of  the 
most  vita!  interest  to  the  practitioner.  .A.nd  we  should 
think  any  medical  library  absurdly  incomplete  now 
which  did  not  have  alongside  of  Watson,  Graves,  and 
Tanner,  the  'Clinical  Medicine'  of  Trousseau." — 
London  Lancet. 


"  We  scarcely  know  of  any  book  better  fitted  for 
presentation  to  a  young  man  when  entering  upon  """  ' 
practical  work  of  his  life." — London  Medical  Tii 


the 
'imes 


practi 

ayid  Gazette. 

"  The  publication  of  Trousseau's  Lectures  furnishes 
medical  men  with  one  of  the  best  practical  treatises 
on  disease  as  seen  at  the  bedside.  The  conversational 
style  adopted  by  the  author  lends  animation  to  the 
work,  and  the  translator  deserves  credit  for  having  so 
well  preserved  the  easy  and  ready  style  of  the  origi- 
nal."— British  and  Foreign  Medico-Chirurgical  Re- 
view. 


TIDY,  MODERN  CHEMISTRY. 

A  Hand-Book  of  Modern  Chemistry.     Organic  and  Inorganic.     By  C.  Mey- 
MOTT  Tidy,  m.d.     8vo.  Price  $5.00 

"We  doubt  if  any  other  chemical  work  containing  so  large  an  amount  of  information  could  be  procured." — 
Dttblin  Medical  yournal. 


38  PRESLEY  BLAKISTON'S 

TILT,  THE  CHANGE  OF  LIFE  IN  WOMEN. 

The  Change  of  Life  in  Health  and  Disease.  A  Practical  Treatise  on  the 
Diseases  incidental  to  Women  at  the  Dechne  of  Life.  By  Edward  John  Tilt, 
M.D.     Fourth  London  Edition.     8vo.  Price,  Cloth,  fi.25;  Paper  cover,  .75 

"  We  believe  Dr.  Tilt  brings  much  more  than  ordinary  merit  to  bear  on  his  subject,  and  handles  it  accord- 
ingly.    Few  books  are  issued  that  are  more  indispensable  to  the  general  practitioner." — Phila.  Med.  Times. 

"  Dr.  Tilt's  clear  and  concise  style  makes  the  book  at  once  a  pleasant  one  to  read  and  an  easy  guide  to  follow, 
and  we  are  quite  sure  it  is  the  most  valuable  one  we  have  on  the  subject." — Boston  Med.  &=  Surg.  Journal. 

"  The  best  work  on  the  subject." — London  Lancet. 

TOMES,  DENTAL  ANATOMY.     Second  Edition. 

A  Manual  of  Dental  Anatomy,  Human  and  Comparative.  By  C.  S.  Tomes, 
D.D.s.     With  179  Illustrations.     Second  Edition,     i2mo.  Price  $4.25 

TOMES,  DENTAL  SURGERY. 

A  System  of  Dental  Surgery.  By  John  Tomes,  f.r.s.  The  Second  Edition, 
Revised  and  Enlarged.     By  C.  S.  Tomes,  d.d.s.     With  263  Illustrations.     i2mo. 

Price  $5.00 

"  We  rejoice  that  such  books  as  these  (Dr.  Tomes'  Works)  are  demanded  by  the  profession,  and  that  the  men 
to  write  them  are  furnished  by  the  profession. "^i?fKi'«/  Cosmos. 

TAFT,  OPERATIVE  DENTISTRY.     Fourth  Edition. 

A  Practical  Treatise  on  Operative  Dentistry.  By  Jonathan  Taft,  d.d.s. 
Fourth  Revised  and  Enlarged  Edition.     Over  100  Illustrations.     Bvo. 

Price,  Cloth,  ^4.25  ;  Leather,  5.00 

"All  the  important  operations,  in  all  their  modifica-  |  "It  is  a  thorough  and  complete  treatise  on  the  Art 
twns,  are  clearly  discussed  by  the  author,  and  the  of  Practical  Dentistry." — London  Medical  Times  and 
work  is  highly  practical  throughout." — Dental  Regis-        Gazette, 

ter.  \ 

TANNER,  INDEX  OF  DISEASES.     Second  Edition. 

An  Index  of  Diseases  and  their  Treatment.  By  Thos.  Hawkes  Tanner,  m.d., 

F.R.c.P.     Sixth  Edition.     Revised  and  Enlarged.     By  W.  H.  Broadbent,  m.d. 

With  Additions.     Appendix  of  Formulse,  etc.     Bvo.  Price  ^3.00 

By  this  useful  hand-book  the  character  of  any  disease  may  be  determined  in  a 

moment,  and  the  general  outline  of  treatment  pursued  by  the  best  authorities  made 

apparent. 

"  Finally,  a  chapter  on  the  climates,  countries,  mine- 
ral springs,  etc.,  best  adapted  to  the  various  classes  of 
invalids,  makes  this  work  the  most  complete  practi- 
tioner's manual  that  we  have  yet  seen. — Chicago  Medi- 
cal Tiines. 


"  This  work,  like  others  from  the  gifted  author,  has 
already  won  for  itself  a  reputation."  .  .  .  "  It  is 
in  truth  what  its  title  indicates." — New  York  Medical 
Record. 


BY   same  author. 

THE  DISEASES  OF  INFANCY. 

A  Practical  Treatise  on  the  Diseases  of  Infancy  and  Childhood.  Third  Edi- 
tion. Carefully  Revised  and  inuch  Enlarged.  By  Alfred  Meadows,  m.d. 
8vo.  Price  $3.00 

Recommended  as  a  Text-book  at  Jefferson  Medical  College  and  other  schools  of 
Medicine. 

"One  of  the  most  careful,  ornate,  and  accessible  1  "We  consider  the  views  of  the  author  on  the  subject 
manuals  on  the  subject." — London  Lancet.  of  therapeutics  as    rational   in  the  highest  degree." — 

1    Boston  Medical  and  Surgical  yoiirnal. 

MEMORANDA  OF  POISONS. 

A  Memoranda  of  Poisons  and  their  Antidotes  and  Tests.  Fourth  American 
from  the  Last  London  Edition.     Revised  and  Enlarged.  Price  .75 

This  most  complete  Toxicological  Manual  should  be  within  reach  of  all  physi- 
cians and  pharmacists,  and  as  an  addition  to  every  family  library,  would  be  the 
means  of  saving  life  and  allaying  pain  when  the  delay  of  sending  for  a  physician 
would  prove  fataL 


PUBLICA  TIONS.  39 


TIBBETS,  MEDICAL  ELECTRICITY. 

A  Hand-book  of  Medical  Electricity.  Giving  full  directions  for  its  Applica- 
tion, etc.     By  Herbert  Tibbets,  m.d.     64  Illustrations.     8vo. 

TOLAND,  PRACTICAL  SURGERY. 

Lectures  on  Practical  Surgery.  By  H.  H.  Toland,  m.d.,  Professor  of  Surgery, 
University  of  California.  Second  Edition.  With  Additions  and  Numerous  Illus- 
trations.    8vo.  Price,  Cloth,  ^4.50;  Leather,  ^5.00 

TRANSACTIONS  OF  THE  COLLEGE  OF  PHYSICIANS. 

The  Transactions  of  the  College  of  Physicians  of  Philadelphia.  New  Series. 
Vols.  I,  II,  III,  IV  and  V.     8vo.  Price,  per  volume,  $2.50 

TYSON,  BRIGHT'S  DISEASE  AND  DIABETES. 

A  Treatise  on  Diabetes  and  Bright's  Disease.  With  Especial  Reference  to 
Pathology  and  Therapeutics.  By  James  Tyson,  m.d.,  Professor  of  Pathology 
and  Morbid  Anatomy  in  the  University  of  Pennsylvania.  With  Colored  Plate's 
and  many  Wood  Engravings.     Svo.  Price  ;f3.5o 


"This  volume  is  the  outcome  of  some  fifteen  years' 
special  study  and  observation,  and  will  be  found  to  be 
a  very  well  prepared  monograph His  direc- 
tions are  clear  and  minute. — Med.  and  Surg.  Reporter. 


"  The  symptoms  are  clearly  defined,  and  the  treat- 
ment is  exceedingly  well  described,  so  that  every  one 
reading  the  book  must  be  profited." — Cincinnati  Lan- 
cet and  Clinic. 


BY   SAME   AUTHOR. 

GUIDE  TO  THE  EXAMINATION  OF   URINE. 

A  Practical  Guide  to  the  Examination  of  Urine.  For  the  use  of  Physicians  and 

Students.    With  Colored  Plate,  and  Numerous  Illustrations  Engraved  on  Wood. 

Third  Edition.     i2mo.  Price  $1.50 

Advantage  has  been  taken,  in  bringing  out  a  new  edition  of  this  work,  not  only  to 

correct  the  previous  one,  but  to  make  such  additions  of  new  Facts  and  Processes  as 

would  add  to  its  value  without  materially  increasing  its  size. 

"Dr.  Tyson  commences  with  a  short  account  of  the  theory  of  renal  secretion,  the  physical  and  chemical  charac- 
ters of  the  urine,  and  the  reagents  and  apparatus  used  in  its  analysis.  Excellent  rules  are  then  given  for  detecting 
the  presence  of  albumen,  sugar,  coloring-matters,  bile,  urea,  uric  acid,  chlorides,  phosphates  and  sulphates  ;  and 
minute  instructions  for  approximative  and  quantitative  determination  of  most  of  those  ingredients  by  volumetric 
analysis  are  supplied." — Pliiladelphia  Medical  Times. 

"We  have  experienced  both  pleasure  and  profit  ftom  the  perusal  of  this  book.  It  is  agreeably  written,  contains 
much  practical  information,  and  is,  we  believe,  a  reliable  and  satisfactory  guide  to  the  clinical  examination  ot 
urine.  We  can  recommend  Dr.  Tyson's  book  as  one  that  amply  supplies  the  clinical  needs  of  the  physician." — 
Dublin  Journal  of  Medical  Science. 

THE  CELL  DOCTRINE.     Second  Edition. 

The  Cell  Doctrine.  Its  History  and  Present  State.  With  a  Copious  Biblio- 
graphy of  the  subject.  Illustrated  by  a  Colored  Plate  and  Wood  Cuts.  Second 
Edition.     Svo.  Price  %i.oo 

TURNBULL,  ARTIFICIAL  ANiESTHESIA. 

The  Advantages  and  Accidents  of  Artificial  Anaesthesia ;  Its  Employment  in 
the  Treatment  of  Disease ;  Modes  of  Administration  ;  Considering  their  Rela- 
tive Risks;  Tests  of  Purity;  Treatment  of  Asphyxia;  Spasms  of  the  Glottis; 
Syncope,  etc.  By  Laurence  Turnbull.  m.d.,  ph.g.,  Aural  Surgeon  to  Jeffer- 
son College  Hospital,  etc.  Second  Edition.  Revised  and  Enlarged.  With  27 
Illustrations  of  Various  Forms  of  Inhalers,  etc.     i2mo.  Price  #1.50 

"  Ansesthesia  is  a  subject  of  great  interest  and  importance  to  physicians  .ind  dentists,  and  everything  that  will 
aid  them  in  better  understanding  the  subject  is  sought  with  great  avidity.  This  work  we  regard  as  the  best  aid  in 
the  study  of  the  subject,  and  it  presents  the  subject  up  to  the  present  hour." — Dental  Register. 

TEALE,  DANGERS   TO    HEALTH.     Third  Edition. 

A  Pictorial  Guide  to  Domestic  Sanitary  Defects.  By  T.  Pridjin  Teale,  m.d., 
F.R.c.s.     With  Colored  Plates.     Svo.  Price  ;^3.3u 


40  PRESLE Y  BLAKISTON'S 


VACHER,  CHEMISTRY. 

A  Primer  of  Chemistr>%     Including  Analysis.     By  Arthur  Vacher.     i8mo. 

Price  .50 

VIRCHOW,  POST-MORTEM  EXAMINATIONS.  Second  Edi- 
tion. 

Post-mortem  Examinations.     A  Description  and  Explanation  of  the  Method 

of  Performing  them  in  the  Dead  House  of  the  Berlin  Charite  Hospital,  with 
especial  reference  to  Medico-legal  Practice.  By  Prof  Virchow.  Translated 
by  Dr.  T.  P.  Smith.     Second  Edition.     i2mo.     With  4  Plates.  Price  gi.25 


"  Its  low  price  and  portability  make  it  accessible  and 
convenient  to  every  surgical  registrar  and  practitioner." 
— British  Medical  yournal. 


"A  most  useful  manual  from    the  pen  of  a  master. 

.  .  .  .  For  thorough  and  systematic  method  in 
the  performance  of  post-mortem  examinations,  there  is 
no  guide  like  it." — Lancet. 

WAGSTAFFE,  HUMAN  OSTEOLOGY. 

The  Student's  Guide  to  Human  Osteology.  By  William  Warwick  Wag- 
STAFFE,  F.R.c.s.  With  23  Lithographic  Plates  of  the  Bones,  Showing  Muscle 
Attachments,  and  60  Wood  Engravings.     i2mo.  Price  $3.00 

WALTON,  DISEASES  OF  THE  EYE.    Third  Edition. 

A  Practical  Treatise  on  Diseases  of  the  Eye.  By  Haynes  Walton,  m.d. 
Third  Edition.  Rewritten  and  Enlarged.  With  five  plain  and  three  colored 
full-page  Plates;  and  many  other  Illustrations,  Test  Types,  etc.  Nearly  1200 
pages.     8vo.  Price  $9.00 

WARNER,  CASE  TAKING. 

The  Student's  Guide  to  Medical  Case  Taking.  By  Francis  Warner,  m.d., 
M.R.C.P.,  etc.     i2mo.     Cloth.  Price  $1.75 

General  Diseases. — Class  i.  Class  2.  Arthritic  Diseases.  Diseases  of  the  Nervous  System.  Of  the  Vas- 
cular System.  Of  the  Respiratory  System.  Of  the  Digestive  System.  Of  the  Liver.  Of  the  Urinary  System. 
Instruction  for  Case  Taking. 

WATERS,  DISEASES  OF  THE  CHEST.     Second  Edition. 

The  Diseases  of  the  Chest.  Their  Clinical  History,  Pathology  and  Treat- 
ment. By  A.  T.  H.  Waters,  m.d.,  Fellow  Royal  College  of  Physicians.  With 
Numerous  Illustrative  Cases  and  Lithographic  Plates.     8vo.  Price  $4.00 

"  The  present  edition  contains  new  chapters  on  haemoptj'sis,  hay  fever,  aortic  regurgitation,  mitral  constriction, 
thoracic  aneurism,  and  the  use  of  chloral  in  certain  diseases  of  the  chest ;  other  chapters  have  received  additions 
of  cases  and  remarks  on  treatment.  Some  characteristic  sphygmographic  tracings  have  also  been  added." — Bos- 
ton Medical  and  Surgical  journal. 

WOOD,  BRAINWORK. 

Brainwork  and  Overwork.     By  Prof.  H.  C.  Wood,  Jr.     32mo. 

Price,  Paper  cover,  .30  ;  Cloth  .50 

BY  SAME   author. 

DENTAL  PATHOLOGY. 

With  Special  Reference  to  the  Anatomy  and  Physiolog}'  of  the  Teeth.  With 
Notes  by  Thos.  B,  Hitchcock,  m.d.,  of  Harvard  University.  105  lUustra- 
trations.     8vo.  Price,  Cloth,  $3.50;  Leather,  34.50 

WHITTAKER,  ON  THE  URINE. 

Student's  Primer  on  the  Urine.  By  J.  Travis  Whittaker,  m.d.,  Physician  to 
Anderson's  College  Dispensary.     With  Illustrations  Etched  on  Copper.     i6mo. 

Price  $1.50 

Physiological  Study  of  Urine — Sensation  in  Passing.  Quantity.  Color.  Odor.  Specific  Gravity.  History 
and  Behavior.  Sediment  or  Deposits.  Chemical  Study  of  Urine — Reaction.  Albumen.  Chlorides.  Ammonia. 
Urea.  Phosphates.  Blood.  Sugar.  Bile.  Microscopical  Study  of  Urine  and  Urinary  Deposits — Amorphous 
Urates.  Uric  Acid.  Triple  Phosphates.  Phosphate  of  Lime.  Feathery  Phosphates.  Oxalate  of  Lime.  Urate 
of  Soda  and  of  Ammonia.     Cystine.     Tyrosine.     Leucine.    Cholesterine.     Epithelium.     Fat  Globules,    etc. 

"The  plates  are  po.ssessed  of  great  versimilitude,  as  well  as  in  other  respects  admirable." — Med.  Times. 

"  Neat  and  concise,  and  the  illustrations  are  very  good  testimony  of  the  claim  which  he  makes  of  the  suitability 
"f  the  etching  needle  for  delineation  of  microscopical  appearances." — Boston  Med.  and  Surg.  yourHol. 


PUBLICA  TIONS.  41 


WEST,  THE  DISEASES  OF  WOMEN.     Fourth  Edition. 

Lectures  on   the    Diseases   of  Women.     By  Charles  West,  m.d.     Fourth 
London  Edition.     Revised  and  in  part  re-written  by  the  Author.     With  Numer- 
ous Additions  by  J.  Mathews  Duncan,  m.d..  Obstetric  Physician  to  St.  Bar- 
tholomew's Hospital     8vo.  Price  $5.00 
Drs.  West  and  Duncan   are,  perhaps,  the  most  celebrated    London  physicians 
giving  attention  to  the  Diseases  of  Women,  and   together  have  made  a  most  com- 
plete work,  either  for  the  physician  or  student. 

WILKES,  PATHOLOGICAL  ANATOMY. 

Lectures  on  Pathological  Anatomy.  By  Samuel  Wilkes,  f.r.s.  Second 
Edition.  Revised  and  Enlarged  by  Walter  Moxon,  m.d.,  f.r.s..  Physician  to 
and  Lecturer  at  Guy's  Hospital,  London.     8vo.  Price  ^6.00 

BY   same   author. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

Lectures  on  Diseases  of  the  Nervous  System,  Delivered  at  Guy's  Hospital, 
London.     New  Edition,  with  Additions,  Numerous  Illustrative  Cases,  etc.     8vo. 

\^Preparing. 

"A  book  of  great  value,  embodying  as  It  does  the  results  of  the  experience  and  observation  of  one  of  the  most 
accomplished  of  the  London  Hospital  Physicians." — Avierica7i  jfournal  of  Medical  Science. 

WRIGHT,  ON  HEADACHES.     Ninth  Thousand. 

Headaches,  their  Causes,  Nature  and  Treatment,  By  Henry  G.  Wright, 
M.D     i2mo.  Price  .50 

WILSON,  ON  DRAINAGE. 

Drainage  for  Health ;  or.  Easy  Lessons  in  Sanitary  Science,  with  Numerous 
Illustrations.  By  Joseph  Wilson,  m.d.,  Medical  Director  United  States  Navy. 
One  Vol.     Octavo.  Price  JSi.oo 


"  Dr.  Wilson  is  favorably  known  as  one  of  the  lead- 
ing American  writers  on  hygiene  and  public  health. 
The  book  deserves  popularity." — Medical  and  Surgi- 
cal Reporter. 


"  Easily  understood,  and  briefly  and  concisely  pre- 
sented."— Providence  Journal. 

"  Will  be  found  of  value." — Boston  Transcript. 

"  Worthy  of  praise  as  a  popular  statement  of  the 


"  Well  written  and  well  illustrated.     Attention  to  its  j    subject." — Boston  Journal  of  Chemistry. 

teachings  may  save  much  disease  and  perhaps  many  "  Will  be  sure  to  be  a  harbinger  of  good  in  every  fam- 

lives." — Cincinnati  Gazette.  ily  whose  good  fortune  it  may  be  to  possess  a  copy." — 

"Interesting  as  well  as  useful." — Philadelphia  Led-  |    Builder  and  Wood  Worker. 
ger. 

BY   SAME   author. 

NAVAL  HYGIENE. 

Naval  Hygiene,  or.  Human  Health  and  Means  for  Preventing  Disease.  With 
Illustrative  Incidents  derived  from  Naval  Experience.  Illustrated.  Second 
Edition.     Svo.  Price  ^3.00 

WILSON,    HOW  TO  LIVE. 

Health  and  Healthy  Homes.  A  Guide  to  Personal  and  Domestic  Hygiene. 
By  George  Wilson,  m.d.,  Medical  Officer  of  Health.  Edited  by  Jos.  G. 
Richardson,  m.d..  Professor  of  Hygiene  at  the  University  of  Pennsylvania. 
314  pages.     i2mo.  Price  $  1. 00 

Chapter  \. — Introductory,  page  17.  II.  The  Human  Body,  33.  iii.  Causes  of  Disease,  66.  iv.  Food  and 
Diet,  119.  V.  Cleanliness  and  Clothing,  169.  vi.  Exercise,  Reoreation  and  Training,  187.  vil.  Home  and  Its 
Surroundings,  Drainage,  Warming,  etc.,  221.     viu.   Infectious  Diseases  and  their  Prevention,  269. 

"A  most  useful,  and  in  every  way,  .icceptable  book." — New  York  Herald. 

"  Marked  throughout  by  a  sound,  scientific  spirit,  and  an  absence  of  all  hasty  generalizations,  sweeping  asser- 
tions, and  abuse  cf  statistics  in  support  of  the  writer's  particular  views.  .  .  .  We  cannot  speak  too  highly  of 
a  work  which  we  have  read  with  entire  satisfaction." — Medical  Timet  and  Gazette. 

BY    SAME    author. 

A  HAND-BOOK  OF  HYGIENE 

And  Sanitary  Science.  With  Illustrations.  Fourth  Edition.  Revised  and 
Enlarged.     Svo.  Price  ^2.75 


42  PRESLEY  BLAKISTON'S 

WILSON,  HUMAN  ANATOMY.     Tenth  Edition. 

The  Anatomist's  Vade-Mecum.  General  and  Special.  By  Prof.  Erasmus  Wil- 
son. Edited  by  George  Buchanan,  Professor  of  Clinical  Surgery  in  the  Uni- 
versity of  Glasgow ;  and  Henry  E.  Clark,  Lecturer  on  Anatomy  at  the  Royal 
Infirmary  School  of  Medicine,  Glasgow.  Tenth  Edition.  With  450  Engravings 
(including  26  Colored  Plates).     Crown  8vo.  Price  $6.00 

Recommended  as  a  Text-book  at  Rush  Medical  College,  Chicago  ;  Bellevue  Hos- 
pital, New  York;  St.  Louis  Medical  College;  Yale  and  Dartmouth  Schools;  and 
many  other  Colleges. 

"The  present  edition  of  the  'Anatomist's  Vade-mecum,'  has  been  prepared  under 
the  same  editorial  control  as  the   Ninth  Edition. 

"  Numerous  additional  wood  cuts  have  been  introduced,  and  full-page  engravings 
of  the  bones,  which  have  been  drawn  and  engraved  with  great  care,  to  secure  ac- 
curacy, and  to  make  them  not  mere  anatomical  diagrams,  but  artistic  pictiures." 

BY   SAME  AUTHOR. 

HEALTHY  SKIN.     Eighth  Edition. 

A  Practical  Treatise  on  the  Skin  and  Hair ;  their  Preservation  and  Manage- 
ment.    Eighth  Edition.     i2mo.     Paper.  Price  ^1.00 

WILSON,  SEA  VOYAGES  FOR  HEALTH. 

The  Ocean  as  a  Health  Resort.  A  Hand-book  of  Practical  Information  as  to 
Sea  Voyages,  for  the  Use  of  Tourists  and  Invahds.  By  Wm.  S.  Wilson,  l.r.c.p. 
Lond.,  m.r.c.s.e.  With  a  Chart  showing  the  Ocean  Routes,  and  Illustrating  the 
Physical  Geography  of  the  Sea.     Crown  8vo.  Price  $2.50 

Chapter  I.  Curative  Effects  of  the  Ocean  Climate.  2.  The  Various  Health  Voyages.  3.  Time  of  Starting — 
Choosing  a  Ship.  4.  Preliminary  Arrangements.  5.  Life  at  Sea.  6.  Climate  and  Weather.  7.  Management  of 
the  Health  at  Sea.  8.  Occupations  and  Amusements  at  Sea.  9.  Objects  of  Interest  at  Sea.  10.  End  of  the 
Voyage — Future  Plans.  11.  The  Homeward  Voyage.  12.  Australia:  its  CUmate,  Cities,  and  Health  Resorts. 
13.  South  Africa  and  its  Climate.     14.  The  Meteorology  of  the  Ocean. 

Appendix  A. — Outfit  Required  for  a  Voyage  to  Australia.  B.  Names  and  Addresses  of  some  of  the  Principal 
Shipping  Firms. 

"All  the  information  is  supplied  by,  or  based  upon,  the  actual  experience  of  the  author;  and  the  book  may  be 
confidently  recommended  to  all  who  have  to  undertake,  without  previous  experience,  a  sea  voyage  of  any  length. 
Medical  men  may  consult  it  with  advantage,  and  commend  it  to  those  patients  whom  they  may  advise  to  try  the 
effect  of  a  long  voyage  at  sea." — Medical  Times  and  Gazette. 

"  We  have  read  every  page  of  this  book,  and  have  derived  both  instruction  and  amusement." — Lancet. 

WELLS,  OVARIAN  AND  UTERINE  TUMORS.     Just  Out. 

The  Diagnosis  and  Surgical  Treatment  of  Ovarian  and  Uterine  Tumors,     By 

T.  Spencer  Wells,  m.d.     Illustrated.     8vo.  Price,  Cloth,  $7.00 

So  long  a  time  having  elapsed  since  Dr.  Wells  has  collected  the  results  of  his 

large  experience  in  book  form,  the  present  volume  will  be  eagerly  looked  for  by  all 

interested  in  this  very  important  subject. 

WOLFE,  ON  DISEASES  OF  THE  EYE. 

A  Practical  Treatise  on  Diseases  and  Injuries  of  the  Eye.  Bemg  a  Course  of 
Systematic  and  Chnical  Lectures  to  Students  and  Medical  Practitioners.  By  M. 
Wolfe,  f.r.c.p.e.,  Senior  Surgeon  to  the  Glasgow  Ophthalmic  Institution,  etc. 
With  10  Colored  Plates,  and  numerous  other  Illustrations.  Octavo.       Price  ^^7.00 

WALKER,  INTERMARRIAGE. 

Intermarriage,  or,  The  Mode  in  which,  and  the  Causes  why,  Beauty,  Health 
and  Intellect  result  from  certain  Unions ;  and  Deformity,  Disease  and  Insanity 
from  others.     Illustrated.     i2mo.  Price  $1.00 


PUB  Lie  A  TIONS. 


43 


WOODMAN  and  TIDY,  MEDICAL  JURISPRUDENCE. 

Forensic  Medicine  and  Toxicology.  By  \V.  Bathurst  Woodman,  m.d., 
Physician  to  the  London  Hospital,  and  Charles  Meymott  Tidy,  f.c.s.,  Pro- 
fessor of  Chemistry  and  Medical  Jurisprudence  at  the  London  Hospital.  With 
Chromo-Lithographic  Plates,  representing  the  Appearance  of  the  Stomach  in 
Poisoning  by  Arsenic,  Corrosive  Sublimate,  Nitric  Acid,  Oxalic  Acid  ;  the  Spectra 
of  Blood  and  the  Microscopic  Appearance  of  Human  and  other  Hairs ;  and 
Ii6  other  Illustrations.     Large  octavo.     Sold  only  by  Subscription. 

Price,  Cloth,  $7.50;  Medical  Sheep,  $8.50;  Law  Leather,  $8.50 

"  We  have  no  hesitation  in  pronouncing  the  work  to  be  one  of  unusual  merit.  More  readable  than  Taylor, 
more  systematic  in  its  arrangement,  and  more  practical  in  its  instruction,  it  will  prove  to  the  medical  jurist,  not 
less  than  to  the  general  practitioner,  a  storehouse  of  useful  knowledge,  conveyed  in  an  unusually  graphic  style." — 
Dublin  Journal  of  Medical  Science. 

"The  authors  of  this  truly  great  work  have  largely  supplied  the  want  felt,  sooner  or  later,  by  almost  every 
doctor." — Cincinnati  LaKcet  and  Observer. 

"All  the  best  known  works  on  Medical  Jurisprudence  have  been  laid  under  contribution  for  the  production  of 
the  present  volume.  It  contains  almost  everything  that  can  be  found  in  other  works  on  the  subject;  but  it  is  no 
mere  compilation.  Dr.  Woodman  and  Dr.  Tidy  have  both  thought  out  the  subject  for  themselves,  and,  with  rare 
industry  and  acumen,  have  brought  together  a  mass  of  facts  which  is  little  short  of  astounding.  The  book  is 
worthy  to  take  its  place  alongside  of  any  work  on  the  same  subject,  and  must  prove  of  great  use  to  all  who  prac- 
tice in  criminal  courts,  and  to  all  medical  practitioners.  We  have  no  hesitation  in  recommending  it  to  our  read- 
ers."— London  Lancet. 

"  Altogether  the  work  will  rank  with,  the  best  of  its  class  as  a  medico-legal  hand-book,  and  cannot  fail  to  gain 
a  wide  popularity." — New  York  Medical  Record. 

"  It  cannot  be  otherwise  than  a  valuable  contribution  to  the  boundless  subject  of  medical  jurisprudence." — 
Albany  La-ju  yournal. 

"The  scope  of  this  book  is  very  wide,  and  its  execution  worthy  of  all  commendation." — Philadelphia  Legal 
Intelligencer. 

^A^YTHE,  ON  THE  MICROSCOPE. 

The  Microscopist.  A  Manual  of  Microscopy  and  Compendium  of  the  Micro- 
scopic Sciences,  Micro-Mineralogy,  Micro-Chemistry,  Biology,  Histology,  and 
Practical  Medicine.  By  Joseph  H.  Wythe,  a.m.,  m.d.  Fourth  Edition.  252 
Illustrations.     8vo.  Price,  Cloth,  $5.00;  Leather,  $6.00 

An  Index  and  Glossary  have  been  combined  in  this  edition,  so  as  to  be  a  source 
of  valuable  information.  Notices  of  recent  additions  to  the  microscope,  together 
with  the  genera  of  microscopic  plants,  have  been  given  in  an  Appendix. 


"From  what  we  knew  of  the  author  of  this  work,  as 
a  skilled  practical  Microscopist,  a  successful  teacher  of 
the  science,  and  a  practitioner  of  medicine  andsurgery 
of  long  and  varied  experience,  we  had  a  right  to  expect 
agoodbook  from  his  hands.  Our  expectations  are  fully 
realized  in  the  volume  before  us.  The  style  is  clear 
and  distinct,  and  one  reads  the  book  with  the  utmost 
facility  of  comprehension.  It  is  the  more  valuable  to 
the  physician  and  medical  student  on  account  of  its 
closer  application  of  the  microscope  to  medical  subjects 
than  we  find  elsewhere.  The  numerous  plates,  many 
of  which  are  beautifully  colored,  are  not  to  be  excelled. 
We  feel  proud  of  it  as  an  American  production." — 
Pacific  Medical  and  Surgical  Journal. 


"  This  is  one  of  the  most  valuable  text-books  on  mi- 
croscopy ever  offered  to  students  or  practitioners  of 
medicine.  This  edition  has  been  greatly  enhanced  in 
value  by  the  addition  of  chapters  on  the  use  of  the 
microscope  in  pathology,  diagnosis,  and  etiology,  and 
numerous  new  illustrations,  some  of  which  are  from 
Rindfleisch. 

"The  author  very  carefully  brings  out  every  neces- 
sary fact  and  principle  relating  to  the  use  of  the  micro- 
scope, and  now  that  this  instrument  has  become  an  es- 
sential part  of  every  practitioner's  armamentarium,  a 
practical  guide  and  reference  book  is  also  a  necessity, 
and  we  are  fully  warranted  in  reiterating  the  statement 
that  this  is  one  of  the  most  valuable  text-books  ever 
offered  to  students  and  practitioners  of  medicine." — 
The  Cincinnati  Lancet  and  Clinic. 


BY   SAME   AUTHOR, 

DOSE  AND  SYMPTOM  BOOK.     Eleventh  Edition. 

The  Physician's  Pocket  Dose  and  Symptom  Book.  Containing  the  Doses  and 
Uses  of  all  the  Principal  Articles  of  the  Materia  Medica,  and  Original  Prepara- 
tions.    Eleventh  Revised  Edition. 

Price,  Cloth,  $i.oo\  Leather,  with  Tucks  and  Pocket,  $1.25 

"The  chapter  on  Dietetic  Preparations  will  be  found  useful  to  all  practicing  physicians,  most  of  whom  have  but 
Jittle  acquaintance  with  the  mode  of  preparing  the  various  articles  of  diet  for  the  sick." — Boston  Medical  and 
Surgical  Journal. 

"Many  a  hard-worked  practitioner  will  find  it  a  useful  little  work  to  have  on  his  study  table." — Canada  Medical 

and  Surgical  Journal. 


44  PRESLE  V  BLAKISTON'S  PUBLIC  A  TIONS. 

WHEELER,  MEDICAL  CHEMISTRY. 

Medical  Chemistry,  Including  the  Outlines  of  Organic  and  Physiological 
Chemistry.     By  C.  Gilbert  Wheeler,  m.d.     Second  Edition,     i2mo. 

Price  I3.00 
WOAKES,  ON  DEAFNESS  AND  GIDDINESS. 

On  Deafness,  Giddiness  and  Noises  in  the  Head ;  or,  The  Naso-Pharyngeal 
Aspect  of  Ear  Disease.  By  Edward  Woakes,  m.d  ,  Senior  Aural  Surgeon  to 
the  Hospital  for  Diseases  of  the  Throat  and  Chest.  Third  Edition.  Revised  and 
Enlarged,  with  Additional  Illustrations.     i2mo. 

"The    early  demand   for    a   fresh   edition  of  Dr.  |       "This  book,  although  small,  is  evidently  the  result 

Woakes' volume  is  a  sufficient  criticism  of  its  merits.  1    of  much  careful  thought  and  observation.     .     .     .    We 

.     .     .     No  brief  summary  of  his  views  could  do  full  cordially  recommend  the  work  as  original  and  suggest- 

justice  to  the   cogency  and  subtlety  of  his  reasons.  ive,  and  as  being  likely  to  prove  very  useful  in  explain- 

We  prefer  to  commend  the  whole  work  to  the  thought-  ing  both  the  causation  of  symptoms  otherwise  puzzling, 

ful  perusal  of  all  intelligent  medical  practitioners  who  and  their  appropriate  treatment." — Practitioner. 
desire  to  rise  above  the  level  of  mere  routine  empiri- 
cism."— Lancet. 


ILLUSTRATED    BOOKS. 

MEDICINAL  PLANTS. 

Being  Descriptions,  with  original  Figures,  of  the  Principal  Plants  employed  in 
Medicine,  and  an  account  of  their  Properties  and  Uses.  By  Robert  Bentley, 
F.L.S.,  Professor  of  Botany  in  the  King's  College,  and  to  the  Pharmaceutical 
Society,  and  Henry  Trimens,  m.b.,  f.l.s.,  late  Lecturer  on  Botany  at  St. 
Mary's  Hospital  Medical  School.  In  42  Parts,  each,  $2.00,  or  in  4  vols.,  large 
8vo,   with    306  Colored  Plates,  bound  in  half  morocco,  gilt  edged.  $90.00 

AN  ATLAS  OF  TOPOGRAPHICAL  ANATOMY. 

After  Plane  Sections  of  Frozen  Bodies.  By  William  Braune,  Professor  of  Anatomy 
in  the  University  of  Leipzig.  Translated  by  Edward  Bellamy,  f.r.c.s..  Sur- 
geon to  and  Lecturer  on  Anatomy  at  Charing  Cross  Hospital.  With  34  Photo- 
lithographic Plates  and  46  Wood  cuts.     Large  imp.  8vo.  $  8.00 

ATLAS  OF  SKIN  DISEASES. 

Consisting  of  a  Series  of  Illustrations,  with  Descriptive  Text  and  Notes  upon 
Treatment.  By  Tilbury  Fox,  m.d.,  f.r.c.p.,  late  Physician  to  the  Department 
for  Skin  Diseases  in  University  College  Hospital.  With  72  Colored  Plates. 
In  18  Parts,  each,  $1.00  or,  i  Vol.,  Royal  4to,  Cloth.  I20.00 

AN  ATLAS  OF  HUMAN  ANATOMY. 

Illustrating  most  of  the  ordinary  Dissections,  and  many  not  usually  practiced  by 
the  Student.  By  Rickman  J.  Godlee,  M.S.,  f.r.c.s.,  Assistant  Surgeon  to 
University  College  Hospital,  and  Senior  Demonstrator  of  Anatomy  in  Universi- 
ty College.  With  48  imp.  4to  Colored  Plates  (112  Figures),  and  a  volume  of  Ex- 
planatory Text.  $20.00 

A  COURSE  OF  OPERATIVE  SURGERY. 

By  Christopher  Heath,  f.r.c.s..  Home  Professor  of  Clinical  Surgerv'  in  Uni- 
versity College,  and  Surgeon  to  the  Hospital.  With  20  Plates  drawn  from 
Nature  by  M.  Leveille,  and  colored  by  hand  under  his  direction.     4to.     $14.00 

ILLUSTRATIONS  OF  CLINICAL  SURGERY. 

Consisting  of  Plates,  Photographs,  Wood  cuts,  Diagrams,  etc.,  etc.,  illustrat- 
ing Surgical  Diseases,  Symptoms,  and  Accidents  ;  also  Operative  and  other 
Methods  of  Treatment,  with  Descriptive  Letterpress.  By  Jonathan  Hutchin- 
son, F.R.C.S.,  Senior  Surgeon  to  the  London  Hospital.  Vol.  I,  containing  fas- 
ciculi I  to  X,  bound,  with  Appendix  and  Index.  $25.00 
FascicuH  XI  to  XIV.     Ready.                                                              Each,  $2.50 


TWO  JOURNALS  FOR  THREE  DOLLARS. 


THE 


MEDICAL    REGISTER. 

A  MONTHLY  RECORD  OF  THE  LITERATURE  OF  MEDICINE  AND  ALLIED 

SCIENCES,  WITH  NOTES  AND  NEWS  AND  COMPLETE 

LISTS  OF  ALL  NEW  BOOKS. 


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EDITED  BY 

KARL  GROSSMANN,  M.D.,  Liverpool,  and  PRIESTLEY  SMITH,  Birmingham, 
WITH  THE  ASSISTANCE  OF  CO-OPERATORS  AT  HOME  AND  ABROAD. 

This  periodical,  commencing  November,  l88l,  will  present  critical  notices  and  abstracts  of 
current  Ophthalmic  Literature,  British  and  Foreign,  and  will  provide  a  channel  for  the  publi- 
cation of  short  original  articles. 

The  first  two  numbers,  now  ready,  contain  contributions  by  Mr.  Jonathan  Hutchinson, 
Edward  Nettleship,  and  other  distinguished  Ophthalmists. 

Published  Monthly.      Subscription,  per  Annum,  $3.00. 

Volume  I  will  comprise  the  fourteen  numbers  from  November,  1 88 1,  to  December,  1882, 
which  will  be  furnished  for  the  regular  subscription  price  of  32.00,  or  upon  receipt  of  i^J.oo 
both  of  the  above  Journals  will  be  sent,  postage  prepaid. 


The  Mscroscopist. 

WITH  TWO  HUNDRED  AND  FIFTY  ILLUSTRATIONS, 

AND 

©reatly  Enlarged  l>y  the  Addition  of  oyer  200  Pages  of  New  Matter.^ 
By  J.  H.  WYTHE,  A.M.,  M.D., 

Professor  of  Microscopy  and  Bistology  in,  the  Medical  College  of  the  Pacific, 
San  Francisco,  California, 


This  Manual  of  Microscopy  and  Compendium  of  the  Microscopic  Sciences, 
Micro-Mineralogy,  Micro-Chemistry,  Biology,  Histology,  and  Practical  Med- 
icine, in  which  the  Practice  of  Medicine  receives  the  largest  attention, 
makes  this  work  one  of  the  most  complete  Text-Books  known  on  the  sub- 
ject. Matters  of  mere  curiosity  have  been  but  briefly  referred  to,  while 
every  necessary  fact  or  principle  relating  to  the  microscope  has  been  care- 
fully stated  and  classified. 

The  chapters  on  the  use  of  the  microscope  in  Pathology,  Diagnosis,  and 
Etiology,  which  have  been  added  to  this  edition,  have  been  largely  illus- 
trated with  wood-cuts  from  Rindfleisch. 

The  Index  and  Glossary  have  been  combined  in  this  edition  so  as  to  be  a 
source  of  valuable  information,  and  notices  of  recent  additions  to  the  mi- 
croscope, together  with  the  genera  of  microscopic  plants,  have  been  given 
in  an  Appendix. 

No  pains  have  been  spared  to  render  this  manual  a  useful  companion  to 
the  student  of  Nature,  and  an  aid  to  the  progress  of  real  science.  Cloth, 
$5.00 ;  Sheep,  $6.00. 

"From  what  we  knew  of  the  author  of  this  work,  as  a  skilled  practical  Microscopist, 
a  successful  teacher  of  the  science,  and  a  practitioner  of  medicine  and  surgery  of  long 
and  varied  experience,  we  had  a  right  to  expect  a  good  book  from  his  hands.  Our  ex- 
pectations are  fully  realized  in  the  volume  before  us.  In  a  little  over  400  pages  he  has 
condensed  almost  everything  of  importance  relating  to  the  subject.  The  style,  though 
almost  aphorismal,  is  clear  and  distinct,  and  one  reads  the  book  with  the  utmost  facility 
of  comprehension.  It  is  the  more  valuable  to  the  physician  and  medical  student  on 
account  of  its  closer  application  of  the  microscope  to  medical  subjects  than  we  find  else- 
where. Too  much  praise  cannot  be  bestowed  on  the  mechanical  execution  of  the  volume. 
The  numerous  plates,  many  of  which  are  beautifully  colored,  are  not  to  be  excelled. 
Added  to  this,  the  large  and  clear  type  and  the  fine  quality  of  paper  make  it  a  most 
comely  book.  We  feel  proud  of  it  as  an  American  production,  dividing  its  authorship 
and  execution  between  the  extreme  west  and  east  teriitorial  limits  of  the  Kepublic." — 
Pacific  Medical  and  Surgical  Journal. 

"This  is  one  of  the  most  valuable  text-books  on  microscopy  ever  offered  to  students  or 
practitioners  of  medicine.  This  edition  has  been  greatly  enhanced  in  value  by  the  ad- 
dition of  chapters  on  the  use  of  the  microscope  in  pathology,  diagnosis,  and  etiology, 
and  numerous  new  illustrations,  some  of  which  are  from  Rindfleisch. 

"  The  author  very  carefully  brings  out  every  necessary  fact  and  principle  relating  to 
the  use  of  the  microscope,  and  now  that  this  instrument  has  become  an  essential  part  of 
every  practitioner's  armamentarium,  a  practical  guide  and  reference  book  is  also  a  ne- 
cessity, and  we  are  fully  warranted  in  reiterating  the  statement  that  this  is  one  of  the 
most  valuable  text-books  ever  offered  to  students  and  practitioners  of  medicine." — The 
Cincinnati  Lancet  and  Clinic. 

P.  BLAKISTON,  SON  &  CO.,  PulbUsliers, 

PHILADELPHIA. 


MEDICAL  TEXT-BOOKS 


PUBLISHED   AND    FOR  SALE  BY 


P.  Blakiston,  Son  &  Co., 

i0i2  WALNUT   STREET,   PHILADELPHIA. 


Day,  Diseases  of  Children.     A  Practical  and  Systematic  Text-book.     8vo.     Cloth,  $^.OOi 
leather,  ^6.00. 

Mackenzie,  Diseases  of  the  Throat  and  Nose.     Author's  Edition,  with  the   112  Original 

Illustrations.     8vo.     Cloth,  ^4.00;  leather,  ^5.00. 
Holden,  Practical  Anatomy.     Fourth  Edition.     Illustrated.     Cloth,  ^5.50. 
Bloxam,   Chemistry,  Organic   and    Inorganic.     The  most  complete  Text-book.     Fourth 

Edition.     284  Illustrations.     Cloth,  ^4.00. 

Byford,  The  Medical  and  Surgical  Diseases  of  Women.     A  New  Edition;  Rewritten, 
with  New  Illustrations.     8vo.     Cloth,  ^5.00;   leather,  ;g6.oo. 

Carpenter,    The    Microscope   and    Its   Revelations.     Sixth   Edition.     500   Illustrations 

Cloth,  ^5.50. 
Beale,  How  To  Work  With  the   Microscope.     Fifth  Edition.     400  Illustrations.     Svo 

Wilson,   Human  Anatomy.     Tenth  London  Edition.     450  Wood-cuts  and  26  Full-pag« 

Colored  Plates.     Cloth,  6.00;  leather,  ^7.00. 
Roberts,  Handbook  of  the  Practice  of  Medicine.     Octavo.     Cloth,  ^5.00;  leather,  ^6.00. 
Aitken,  Science   and   Practice  of  Medicine.      Third   American,   from   the   Sixth   London 

Edition.     Two  volumes,  royal  octavo.     Cloth,  f  12.00;  Leather,  $14,00. 
Sanderson,  Handbook  for    the    Physiological    Laboratory.      Exercises   for   Students   in 

Physiology  and  Histology.    353  Illustrations.    One  volume.    Cloth,  $5.00  ;  Leather,  $6.00 
Cazeaux,    Text-book  of    Obstetrics.     From   the   Seventh   French   Edition.     Revised   and 

Greatly  Enlarged,  with  Illustrations.     Cloth,  $6.00;  Leather,  $7.00. 
Heath,  Practical  Anatomy  and  Manual  of  Dissections.     Fifth  London  Edition.     Enlarged. 

24  Colored  plates,  and  nearly  300  other  Illustrations.     $5.00. 
Quiz-Compends.     A  Series  of  Handbooks  for  use  in  Quiz  Classes  and  Examinations,     Based 

on  the  best  Text-books  and  Lectures  of  prominent  Professors,  they  will  be  found  of  much 

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Meigs  and  Pepper,  Practical  Treatise  on  the  Diseases  of   Children.     Sixth  Edition 

Cloth,  |6.oo;   leather,  ^7.00. 
Wythe,  Microscopist.     A  Manual  of  Microscopy.     Fourth  Edition,  Revised,  with  252  Illus> 

trations.     Cloth  .^5.00;   leather,  ^6.00. 

Tanner  and  Meadows,  Diseases  of  Infancy  and  Childhood.    Tliird  Edition.    Cloth,  ^3.00. 
Biddle,  Materia  Medica  for  Students.     The  Eighth  Revised  and  Enlarged  Edition,  with 
Illustrations.     $4.00. 

Woodman  and   Tidy,   Forensic  Medicine  and  Toxicology.     Illustrated.     Svo.     Cloth, 
$7.50;    sheep,  ^8.50. 

Hewitt,  Diagnosis  and  Treatment  of  the  Diseases  of  Women.     Third  Edition.     Cloth, 

;g4.oo;   leather,  ^5.00. 

Headland,  on  the  Action  of  Medicines.     Sixth  American  Edition.     ^3.00. 

Meadows,  Manual  of  Midwifery.     Third  Enlarged  Edition,  including  the  Signs  and  Symp 

toms  of  Pregnancy,  etc.     Illustrated.     ^2.00. 
Fothergill,  Complete  Manual  of  the  Diseases  of  the  Heart  and   Their    Treatment, 

Second  Edition.     ^3.50. 

Tanner,  Index  of  Diseases  and  Their  Treatment.     A  New  Edition.     ^3.00. 


ITS'  PRACTICE  OF  MEDICINE. 

A  Ne^A^  Enlarged  Edition, 

JUST  READY. 

Uniformly  commended  by  the  Profession  and  the  Press. 

A  HAND-BOOK  OF  THE  THEORY  AND  PRACTICE  OF  MEDI- 
CINE.    By  Frederick  T.  Roberts,  M.D.,  M.R.C.F.,  Assistant  Pro- 
fessor and  Teacher  of  Clinical  Medicine  in  University  College  Hospital, 
Assistant  Physician  in  Brompton  Consumptive  Hospital,  &c.,  &c. 
Third  Edition.     Octavo.     Price,  in  cloth       ....       $5.00 

leather      ....         6.00 
The  Publishers  are  in  receipt  of  numerous  letters  from  Professors  in  the  various  Med- 
ical Schools,  uniformly  commending  this  book ;  whilst  the  following  extracts  from  the 
Medical  Press,  both  English  and  American,  fully  attest  its  superiority  and  great  value 
not  only  to  the  student,  but  also  to  the  busy  practitioner. 

This  is  a  good  book,  yea,  a  very  good  book.  It  is  not  so  full  in  its  Pathology  as  "  Aitken," 
so  charming  in  its  composition  as  "  Watson,"  nor  so  decisive  in  its  treatment  as  "  Tanner; " 
but  it  is  more  compendious  than  any  of  them,  and  therefore  more  useful.  We  know  of  no 
other  work  in  the  English  language,  or  in  any  other,  for  that  matter,  which  competes  with 
this  one.  — Edinburgh  Medical  Journal. 

We  have  much  pleasure  in  expressing  our  sense  of  the  author's  conscientious  anxiety  to 
make  his  work  a  faithful  representation  of  modern  medical  beliefs  and  practice.  In  this  he 
has  succeeded  in  a  degree  that  will  earn  the  gratitude  of  very  many  students  and  practition- 
ers: it  is  a  remarkable  evidence  of  industry,  experience,  and  research.  —  Practitioner. 

That  Dr.  Eoberts's  book  is  admirably  fitted  to  supply  the  want  of  a  good  hand-book  of 
medicine,  so  much  felt  by  every  medical  student,  does  not  admit  of  a  question.  —  Students' 
Journal  and  Hosjntal  Gazette. 

Dr.  Koberts  has  accomplished  his  task  in  a  satisfactory  manner,  and  has  produced  a  work 
mainly  intended  for  students  that  will  be  cordially  welcomed  by  them ;  most  of  the  observa- 
tions on  treatment  are  carefully  written  and  worthy  of  attentive  study ;  the  arrangement  is 
good,  and  the  style  clear  and  simple.  — London  Lancet. 

It  contains  a  vast  deal  of  capital  instruction  for  the  student,  much  valuable  matter  in  it  to 
commend,  and  merit  enough  to  insure  for  it  a  rapid  sale. — London  Medical  Times  and  Gazette. 

There  are  great  excellencies  in  this  book,  which  will  make  it  a  favorite  both  with  the 
accurate  student  and  busy  practitioner.  The  author  has  had  ample  experience. — Richmond 
and  Louisville  Journal. 

We  confess  ourselves  most  favorably  impressed  with  this  work.  The  author  has  performed 
his  task  most  creditably,  and  we  cordially  recommend  the  book  to  our  reader^.  —  Canada 
Medical  and  Surgical  Journal. 

A  careful  reading  of  the  book  has  led  us  to  believe  that  the  author  has  written  a  work 
more  nearly  up  to  the  times  than  any  that  we  have  seen ;  to  the  student,  it  will  be  a  gift  of 
priceless  value.  — Detroit  Review  of  Medicine. 

Our  opinion  of  it  is  one  of  almost  unqualified  praise.  The  style  is  clear,  and  the  amount  of 
useful  and,  indeed,  indispensable  information  which  it  contains  is  marvellous.  We  heartily 
recommend  it  to  students,  teachers,  and  practitioners.  —  Boston  Med.  and  Surgical  Journal. 

It  is  of  a  much  higher  order  than  the  usual  compilations  and  abstracts  placed  in  the  hands 
of  students.  It  embraces  many  suggestions  and  hints  from  a  carefully  compiled  hospital 
experience ;  the  style  is  clear  and  concise,  and  the  plan  of  the  work  very  judicious. — Medical 
and  Surgical  Reporter. 

It  is  unsurpassed  by  any  work  that  has  fallen  into  our  hands  as  a  compendium  for  students 
preparing  for  examination.   It  is  thoroughly  practical  and  fully  up  to  the  times. — The  Clinic. 

We  find  it  an  admirable  book.  Indeed,  we  know  of  no  hand-book  on  the  subject  just  now 
to  be  preferred  to  it.  We  particularly  commend  it  to  students  about  to  enter  upon  the 
jn-actice  of  their  profession.  —  St.  Louis  Medical  and  Surgical  Journal. 

If  there  is  a  book  in  the  whole  of  medical  literature  in  which  so  much  is  said  in  so 
few  words,  it  has  never  come  within  our  reach.  So  clear,  terse,  and  pointed  is  the  style  ; 
so  accurate  the  diction,  and  so  varied  the  matter  of  this  book,  that  it  is  almost  a  dictionary 
of  practical  medicine.  —  Chicago  Medical  Journal. 


DUE  DATE 


201-6503 


Printed 
In  USA 


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0027673740 


